Problems related to Abuse or Neglect

PROBLEMS RELATED TO ABUSE
OR NEGLECT
PRESENTED BY
ONISHA NIRJO N M

INTRODUCTION
Abuse is on the rise in this society. Books, newspapers, movies, and
television inundate their readers and viewers with stories of “man’s inhumanity
to man” (no gender bias intended).
Nearly 5.3 million intimate partner victimizations occur each year among
United States women ages 18 and older, and 3.2 million occur among men
(Centers for Disease Control and Prevention [CDC], 2006). More injuries are
attributed to intimate partner violence than to all rapes, muggings, and
automobile accidents combined.
Rape is vastly underreported in the United States. Because many of these
attacks occurring daily go unreported and unrecognized, sexual assault can be
considered a silent-violent epidemic in the United States today.

DEFINITIONS
Abuse
The maltreatment of one person by another.
Battering
A pattern of coercive control founded on and supported by physical and/or
sexual violence or threat of violence of an intimate partner.
Neglect
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 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.
Incest
The 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 (e.g., caretakers, stepparents, stepsiblings) (Sadock & Sadock,
2007).
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.

DSM V CLASSIFICATION
• Abuse and Neglect (717)
• Child physical abuse (717)
• Child sexual abuse (718)
• Child Neglect (718)
• Child psychological abuse (719)
• Adult maltreatment and neglect problems (720)
• Spouse or partner violence, physical (720)
• Spouse or partner violence, sexual (720)
• Spouse or partner violence, neglect (721)
• Spouse or partner violence, psychological (721)
• Adult abuse by Non-spouse or Non-partner (722)

ABUSE
Abuse affects all populations equally.
It occurs among all races, religions, economic
classes, ages, and educational backgrounds.
The phenomenon is cyclical in that many abusers
were themselves victims of abuse as children

PREDISPOSING FACTORS OF ABUSE
BIOLOGICAL THEORIES
Neurophysiological Influences
Various components of the neurological system in both humans and animals
have been implicated in both the facilitation and inhibition of aggressive impulses.
Areas of the brain that may be involved include the temporal lobe, the limbic system,
and the amygdaloid nucleus (Tardiff, 2003).
Biochemical Influences
Studies show that various neurotransmitters in particular norepinephrine,
dopamine, and serotonin—may play a role in the facilitation and inhibition of
aggressive impulses (Hollander, Berlin, & Stein, 2008). This theory is consistent
with the “fight or flight” arousal described by Selye (1956) in his theory of the
response to stress

Genetic Influences
The XYY syndrome has been found to contribute to aggressive behavior
in a small percentage of cases (Sadock & Sadock, 2007). The evidence linking this
chromosomal aberration to aggressive and deviant behavior has not yet been firmly
established.
Disorders of the Brain
Organic brain syndromes associated with various cerebral disorders
have been implicated in the predisposition to aggressive and violent behavior. Brain
tumors, particularly in the areas of the limbic system and the temporal lobes; trauma
to the brain, resulting in cerebral changes; and diseases, such as encephalitis (or
medications that may effect this syndrome) and epilepsy, particularly temporal lobe
epilepsy, have all been implicated.

PSYCHOLOGICAL THEORIES
Psychodynamic Theory
The psychodynamic theorists imply that unmet needs for
satisfaction and security result in an underdeveloped ego and a weak superego.
It is thought that when frustration occurs, aggression and violence supply this
individual with a dose of power and prestige that boosts the self-image and
validates a significance to his or her life that is lacking. The immature ego
cannot prevent dominant id behaviors from occurring, and the weak superego
is unable to produce feelings of guilt.

Learning Theory
Children learn to behave by imitating their role models. 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 whose parents disciplined with physical punishment are more likely to
behave in an abusive manner as adults (Tardiff, 2003). Adults and children alike
model many of their behaviors after individuals they observe on television and in
movies
Unfortunately, modeling can result in maladaptive as well as
adaptive behavior, particularly when children view heroes triumphing over
villains by using violence. It is also possible that individuals who have a
biological predisposition toward aggressive behavior may be more susceptible to
negative role modeling.

SOCIOCULTURAL THEORIES
Societal Influences
Social scientists believe that aggressive behavior is primarily a product of one’s
culture and social structure. American society essentially was founded on a general
acceptance of violence as a means of solving problems. The effect of the growing gap
between the rich and poor is mediated through an undermining of social cohesion, or social
capital, and decreased social capital is in turn associated with increased firearm homicide
and violent crime
“All men are created equal” is hypocritical in our society. Societal influences
may also contribute to violence when individuals realize that their needs and desires are not
being met relative to other people (Tardiff, 2003). When poor and oppressed people find that
they have limited access through legitimate channels, they are more likely to resort to
delinquent behaviors in an effort to obtain desired ends. This lack of opportunity and
subsequent delinquency may even contribute to a subculture of violence within a society.

DOMESTIC VIOLENCE
An ongoing, debilitating experience of physical, psychological,
and/or sexual abuse in the home, associated with increased isolation from the
outside world and limited personal freedom and accessibility to resources.
American Medical Association (2007)
Physical abuse between domestic partners may be known as spouse
abuse, domestic or family violence, wife or husband battering, or intimate
partner or relationship abuse.

The most common reason for not reporting among women was “fear of reprisal.”
Among men, the most common reason for not reporting was because it was a
“private or personal matter.”

Profile of the Victim
• Battered women represent all age, racial, religious, cultural, educational, and
socioeconomic groups.
• They may be married or single, housewives or business executives.
• Many women who are battered have low self-esteem, commonly adhere to
feminine sex-role stereotypes, and often accept the blame for the batterer’s
actions.
• Feelings of guilt, anger, fear, and shame are common.

• Some women who are in violent relationships grew up in abusive homes and may
have left those homes, even gotten married, at a very young age in order to escape
the abuse.
• The battered woman views her relationship as male dominant, and as the battering
continues, her ability to see the options available to her and to make decisions
concerning her life (and possibly those of her children) decreases.
• The phenomenon of learned helplessness may be applied to the woman’s
progressing inability to act on her own behalf.
• Learned helplessness occurs when an individual comes to understand that
regardless of his or her behavior, the outcome is unpredictable and usually
undesirable

Profile of the Victimizer
• Men who batter usually are characterized as persons with low self-esteem.
• Pathologically jealous, they present a “dual personality,” one to the partner
and one to the rest of the world.
• They are often under a great deal of stress, but have limited ability to cope
with the stress.
• The typical abuser is very possessive and perceives his spouse as a
possession.
• He becomes threatened when she shows any sign of independence or attempts
to share herself and her time with others.
• He achieves power and control through intimidation.

• Small children are often ignored by the abuser; however, they may also
become the targets of abuse as they grow older, particularly if they attempt to
protect their mother from abuse.
• The abuser also may use threats of taking the children away as a tactic of
emotional abuse.
• The abusing man typically wages a continuous campaign of degradation
against his female partner.
• He insults and humiliates her and everything she does at every opportunity.
• He strives to keep her isolated from others and totally dependent on him.
• He demands to know where she is at every moment, and when she tells him he
challenges her honesty.

CYCLE OF BATTERING
Phase I The Tension-Building Phase.
Phase II The Acute Battering Incident.
Phase III Calm, Loving, Respite (“Honeymoon”) Phase.

WOMEN HAVE BEEN KNOWN TO STAY IN AN ABUSIVE
RELATIONSHIP BECAUSE
● For the children: She may fear losing custody of the children if she leaves
For financial reasons: She may have no financial resources, access to the
resources, or job skills.
● Fear of retaliation: Her partner may have told her that if she leaves he will
find her and kill her and the children.

● Lack of a support network: She may be under pressure from family
members to stay in the marriage and try to work things out.
● Religious reasons: She may have religious beliefs against divorce. Some
clergy strive only to help save the marriage at all costs (rather than to focus on
stopping the violence).
● Hopefulness: She remembers good times and love in the relationship and
has hope that her partner will change his behavior and they can have good
times again.

CHILD ABUSE
Erik Erikson (1963) stated, “The worst sin is the mutilation of a
child’s spirit.”
Children are vulnerable and relatively powerless, and the effects
of maltreatment are infinitely deep and long lasting. Child maltreatment
typically includes physical or emotional injury, physical or emotional
neglect, or sexual acts inflicted upon a child by a caregiver

Problems related to Abuse or Neglect

PHYSICALABUSE
Physical abuse of a child includes “any physical injury as a result
of punching, beating, kicking, biting, burning, shaking, throwing, stabbing,
choking, hitting (with a hand, stick, strap, or other object), burning, or
otherwise harming a child” (CWIG, 2006a).
Maltreatment is considered whether or not the caretaker intended
to cause harm, or even if the injury resulted from over-discipline or physical
punishment. The most obvious way to detect it is by outward physical signs.
However, behavioral indicators also may be evident.

SIGNS OF PHYSICALABUSE
● Has unexplained burns, bites, bruises, broken bones, or black eyes.
● Has fading bruises or other marks noticeable after an absence from school.
● Seems frightened of the parents and protests or cries when it is time to go home.
● Shrinks at the approach of adults
● Reports injury by a parent or another adult caregiver.
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.

EMOTIONALABUSE
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.
Examples of emotional injury include belittling or rejecting the
child, ignoring the child, blaming the child for things over which he or
she has no control, isolating the child from normal social experiences,
and using harsh and inconsistent discipline.

BEHAVIORAL INDICATORS OF EMOTIONAL INJURY
● Shows extremes in behavior, such as overly compliant or demanding behavior, extreme
passivity, or aggression.
● Is either inappropriately adult (e.g., parenting other children) or inappropriately infantile
(e.g., frequently rocking or head-banging)
● Is delayed in physical or emotional development
● Has attempted suicide
● Reports a lack of attachment to the parent
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.

PHYSICALAND EMOTIONAL NEGLECT
Indicators of Neglect.
The possibility of neglect may be considered when the child
● 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.

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.

SEXUALABUSE OF A CHILD
CAPTA defines sexual abuse as:
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 any 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
form of sexual exploitation of children, or incest with children.

INDICATORS OF SEXUALABUSE
● 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 or
behavior.
● Becomes pregnant or contracts a venereal disease, particularly if younger
than age 14.
● Runs away.
● Reports sexual abuse by a parent or another adult caregiver.

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.

CHARACTERISTICS OF THE ABUSER
Sadock and Sadock (2007) report that 90% of parents who abuse their children were
severely physically abused by their own mothers or fathers.
Additional characteristics that may be associated with abusive parents are
● Experiencing a stressful life situation (e.g., unemployment; poverty)
● Having few, if any, support systems; commonly isolated from others
● Lacking understanding of child development or care needs
● Lacking adaptive coping strategies; angers easily; has difficulty trusting others
● Expecting the child to be perfect; may exaggerate any mild difference the child manifests from
the “usual”

SEXUALASSAULT
Sexual assault is viewed as any type of sexual act in which an individual
is threatened or coerced, or forced to submit against his or her will.
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.
Regardless of the defining source, one common theme always emerges:
Rape is an act of aggression, not one of passion.

TYPES OF RAPE
• Acquaintance rape (called date rape if the encounter is a social
engagement agreed to by the victim) is a term applied to situations in
which the rapist is acquainted with the victim. They may be out on a
first date, may have been dating for a number of months, or merely
may be acquaintances or schoolmates.

• Marital rape, which has been recognized only in recent years as a legal
category, is the case in which a spouse may be held liable for sexual abuse
directed at a marital partner against that person’s will.
• Statutory rape is defined as unlawful intercourse between a person who
is over the age of consent and a person who is under the age of consent.
An adult who has intercourse with a person who is under the age of
consent can be arrested for statutory rape, although the interaction may
have occurred between consenting individuals.

Burgess (2007) identified TWO EMOTIONAL PATTERNS OF
RESPONSE that may occur within hours after a rape
• In the expressed response pattern, the victim expresses feelings of fear,
anger, and anxiety through such behaviors as crying, sobbing, smiling,
restlessness, and tension.
• In the controlled response pattern, the feelings are masked or hidden, and a
calm, composed, or subdued affect is seen.

MANIFESTATIONS OF RAPE
● 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

LONG TERM EFFECTS OF RAPE
• Compounded rape reaction, in which additional symptoms such as
depression and suicide, substance abuse, and even psychotic behaviors may
be noted
• Silent rape reaction, in which the victim 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 the woman is forced
to face another sexual crisis in her life that reactivates the previously
unresolved feelings.

TREATMENT MODALITIES
• Crisis Intervention
• Coping Strategies
• Support groups
• The Safe House or Shelter
• Family Therapy

NURSING MANAGEMENT
● Rape-trauma syndrome related to sexual assault evidenced by verbalizations of
the attack; bruises and lacerations over areas of body; severe anxiety.
● Powerlessness related to cycle of battering evidenced by verbalizations of abuse;
bruises and lacerations over areas of body; fear for her safety and that of her children;
verbalizations of no way to get out of the relationship.
● Delayed growth and development related to abusive family situation evidenced by
sudden onset of enuresis, thumb sucking, nightmares, inability to perform selfcare
activities appropriate for age.

NURSING CARE
1. It is important to communicate the following to the victim of sexual assault:
● You are safe here.
● 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 that you could.

2. Explain every assessment procedure that will be conducted and why it is being
conducted. Ensure that data collection is conducted in a caring, nonjudgmental
manner.
3. Ensure that the client has adequate privacy for all immediate post-crisis
interventions. Try to have as few people as possible providing the immediate care
or collecting immediate evidence.
4. Encourage the client to give an account of the assault. Listen, but do not probe.
5. Discuss with the client whom to call for support or assistance. Provide
information about referrals for aftercare.

REHABILITATIVE MEASURES
• Assistance for a family that finds itself overwhelmed, but that could provide adequate
parenting if certain support were given. Such support could include respite care in the
form of an occasional babysitter, regular day care services, or periodic foster care.
• Practical help with daily household tasks, including managing domestic finances, or
with training in work skills.
• Training in parenting.

• Therapeutic interventions, such as attendance at substance abuse programmes,
treatment for mental illness, or marital counselling.
• Supervision of the home, with a child protection service provider visiting
periodically to evaluate the progress of the child and family. This supervision
may be voluntary on the part of the child’s legal guardians or may be ordered
by the state
• The removal of the alleged perpetrator from the home, while the rest of the
family is kept intact.

• The removal of the child from the home and placement in a relative’s
home, a foster home, or – as a last resort only – residential care.
• Conditions may be attached to the child’s supervision order or temporary
removal from the home. These conditions may include the attendance of
parents at a substance abuse or an anger management programme, the
provision for parents of mental health care, and periodic health checks for
the child.

• respect for the ethnic, religious, cultural and linguistic background of the
family;
• consideration of the physical and developmental level of the child and the
child’s caregivers;
• consideration of the mental health status of the child and the caregivers; •
support for the integrity, stability and autonomy of families by dealing with
them on a basis of mutual consent;
• respect for the importance to the child of continuity of care, upbringing
and stability and of nurturing family relationships;

• a plan to reduce the future risk of maltreatment;
• the removal of obstacles to fulfilling the child’s needs;
• consideration of the child’s wishes and concerns, including those that relate
to temporary care arrangements, physical and mental health care, education,
and religious and cultural issues – given the child’s level of understanding.
The child’s expressed wishes, though, should be considered taking into
account the child’s developmental stage and emotional health, as well as the
nature of bonds between the child and other family members.

Problems related to Abuse or Neglect

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