SEMINAR ONCHILD ABUSE Mr. Ashish Noel M.Sc.Nursing ( Paed)
CHILD ABSUE INTRODUCTION – Child neglect is the most common form of maltreatment. Neglect is generally defined as the failure of a parent or other person legally responsible for the child’s welfare to provide for the child’s basic needs and an adequate level of care.(Nester, 1998 & Kaplan and Labruna, 1999)
TYPE OF NEGLECT – PHYSICAL NEGLECT – involves the deprivation of necessities such as food, clothing, shelter, supervision, medical care & education. EMOTIONAL NEGLECT – refers to failure to meet the child’s needs for affection, attention and emotional nurturance.
PATHOPHYSIOLOGY The pathophysiology is the result of injuries that may be due to beating, twisting the extremities, punching, scalding or burning with cigarettes.
SINGS AND SYMPTOMS Sign and symptoms consist primarily of bruises, scratches, burns, hematomas and fractures of long bones, ribs or skull as well as discomfort and pain. Neglect, is the chronic failure of adults to protect the child from obvious physical danger or to provide the care needed.
ASSESSMENT History Taking Physical Examination X – Ray- stages of healing of several bone lesions. The different diagnosis depends on the particular injuries.
TREATMENT- Appropriate medical, surgical and psychiatric treatment should be promptly initiated.- The law requires that a child suspected of being abused or neglected be reported immediately to child protective services (CPS).- Suspected abuse child should not be discharged from the clinic or office without consulting the country CPS.- Hospitals caring for children should have a team of professionals who are trained & skilled in child abuse recognition, reporting and services. This team should include a pediatrician, a hospital social worker, a pediatric nurse, a psychologist or psychiatrist and a data coordinator.- Provide symptomatic treatment to the child.
Cont……. Provide more intensive surveillance and well child case for the abused and neglected children. Abused children need good physical case and love. Provide psychological support to the child and parents. Provide the counseling to the parents regarding to child rearing, positive parents behaviors and involvement of parents in childs care activity.
PARENTS ANONYMOUS Self – help, non profit groups called parents Anonymous have been organized across the country. Ideally, each abusive individual should have a normal adult who can assume the role of parent. The main objective is to establish a positive parent- child relationship and to restore the parents self confidence by changing old habits one step at a time. These self help groups need the support and encouragement of the nurses as a professional or as a friend.
THEORETICAL PERSPECTIVES ON CHILD ABUSE MENTAL ILLNESS MODEL – This explanation for bike abuse states that parents who abuse their children are mentally ill. The goal is to cure the parent, who will them stop the abuse. This model was developed very early in the identification and treatment of abuse.
ENVIRONMENTAL STRESS MODEL – In this model, two factors interact t precipitate abuse a violent environment and stress. The violent environment can be found either in society or the family. Abusive parents ideologically belong to that segment of society that approves of physical violence against children in certain circumstances. According to this theory, the violence has to be a result of child behavior abuse for no reason is unacceptable. This model is used to explain intergenerational abuse those abuse as children were exposed to an environment that tolerated and even sanctioned child abuse as a method of problem solving.
SOCIAL LEARNING MODEL – This model to explain how humans learn behavior was developed by Bandura (1973). Many human behaviors are learned through observation as well as through behavioral reinforcement. This model of abuse is useful because it includes cultural and family influences.
SOCIAL PSYCHOLOGIC MODEL – This model was proposed by Kempe and Helfer (1972). For abuse to occur, three variables must be present; A special parent, A special child and stress. The parent can be “special” in a number of ways, including being immature having unrealistic expectations of the child, having poor impulse control and failing to recognize and respect the child ah a unique individual. The child can also be special in several ways; “wrong” sex, physically or mentally disabled, “different” from the other children in the family of tem chronic. This is important because of the frequent difference of perception of stress between the two groups and the professionals limited understanding of the parents lifestyle and resources.
HUMAN ECOLOGIC MODEL – This model to explain child abuse was developed by Garbarino (1977). It says that abuse is a result of interactions of the culture, the family, the parent, the bike and stress. It identify the family ah the dysfunctional system, with abuse being a symptoms. This suggests that parents the abused child and other children in the family interact in such a way that abused occur occurs during periods of stress.
PSYCHOLOGIC - SOCIOLOGIC MODEL FOR SEXUAL ABUSE – Finkelhor (1984) has presented a model specification related to sexual abuse. It has 4 components, developed from an individual and a socio cultural level. First, the perpetrator must be motivated to abuse a child sexually. Second, necessary for sexual abuse to occur is the overcoming of internal inhibitors. Third, external inhibitors must be overcome Mothers ability to protect her children. Finally, the resistance of the child must be overcome. Children can play a role in whether they are sexually abuse.
CYCLE OF CHILD ABUSE Many parents who abuse their children were themselves victims of child abuse because they unable to meet their parents needs. These individuals, lacking love and security as children, become lonely adults who, when they are of an age to marry, seek a loving parent figure to care for them.
PHYSICAL ABUSE The deliberate infliction of injuries on a child, usually by the childs caregiver is termed physical abuse. Minor physical injury is responsible for more reported cases of a treatment than major.
FACTORS PREDISPOSINGTO PHYSICAL ABUSE The exact cause of abuse is not known but three major criteria Parental characteristics. Characteristics of child. Environmental characteristics.
Parental Characteristic- Violence, Poverty, Parental history of abuse, Socially isolated, Low self esteem, Less adequate maternal functioning.
Characteristic of Child - No. of children’s, Childs temperament, Position in the family, Additional physical needs if ill or disabled, Activity level or degree of sensitivity to parental needs. Occasionally the abused child is ill e.g. it is mate, unwanted, brain damaged, hyper active or physically disabled.
Environmental Characteristics - Chronic stress, Problem of divorce, Poverty, Unemployment, Poor housing, Frequent relocation, Alcoholism, Drug addiction.
CLINICAL MANIFESTATION - PHYSICAL NEGLECT -SUGGESTIVE PHYSICAL FINDINGS – Failure of Thrive, Signs of mal nutrition such as thin extremities, abdominal distension, Poor personal hygiene, Unclean and in appropriate dress, Evidence of poor health case, such as delayed immunization, untreated infections, frequent colds, Frequent injuries from lack of supervision.SUGGESTIVE BEHAVIORS- Dull and inactive; excessively passive or sleep, Self - stimulatory behaviors, such ah finger - sucking or rocking, Begging or stealing food, Absenteeism from school, Drug or alcohol addiction,
PHYSICAL ABUSE – SUGGESTIVE PHYSICAL FINDINGS – Bruises and Welts -On faces, lips, mouth, back, buttocks, thighs regular patterns descriptive of object used such as belt buckle, hand, wise hanger, chain, wooden spoon, squeeze or pinch mark. Burns- on sole of feet, palms of hand, back or buttocks. Patterns descriptive of object used, such as sound cigar or cigarette burns, immersion in scalding water, rope burns on wrists. Absence of splash marks and presence of symmetric burns. Stun gun injury: lesions circular, fairly uniform (up to 0.5 cm). Fractures and dislocations- Skull, nose or facial structures. Multiple new or old fractures in various stages of healing. Lacerations and abrasions- On back of arms torso, face or external genitalia. Descriptive marks such as from human bites or pulling hair out. Chemical- UN explained repeated poisoning, especially drug overdose.
CONT…. SUGGESTIVE BEHAVIOUR – Wary of physical contact with adults. Apparent fear of parents or going home. Lying very still while surveying environment. In appropriate reaction to injury, such as failure to cry from pain. Withdrawal behavior. Superficial relationship. Lack of reaction to frightening events.
NURSING CARE OF PHYSICALLY ABUSED CHILDRENCHILD AND FAMILY ASSESSMENT – Use age - appropriate methods to assess development; preverbal and young children respond to play therapy with folks that represent family members. Provide age - appropriate support for the child during radio logic and other diagnostic tests. - Document physical injuries. Document observations of child behavior that indicate psychologic and emotional status. With other health care team members, complete the family assessment.
PLANNING AND INITIATING CARE – Assess level of knowledge and skill of parent regarding childcare and development. Identify one nurse as the childs primary care giver. Develop a clearly defined plan of case to be followed by all nurses. Involve older children in developing the plan for their own care. Plan patient care to include parental participation.
INTER DISCIPLINARY PARTICIPATION IN CARE – Provide positive reinforcement for family / parent strengths. Model healthy communication and parenting behavior. Inform parents that child protection services are being notified. Without judging or accusing parents. Explain that the objective of involvement is to strengthen family functioning and prevent future harm to children. Support parents during initial interviews with child protection workers. Assist parents in identifying strategies necessary to prevent future always.
PREVENTION FROM PHYSICAL ABUSE The pediatricians role in primary abuse prevention includes identifying parents at high risk for being unable to accept, love and properly discipline and care for their offspring. The history obtained from all parents should include information about pregnancy planning, pregnancy, emotional and physical health, domestic violence and attitudes about the child and child- rearing experiences. Abuse and serious neglect may be prevented when at- risk families receive intensive training and support during pregnancy and after delivery.
PROGNOSIS – Early studies of abused children returned to their parents without any intervention indicate that about 5 are subsequently killed and that 2 5 are seriously re- injured with comprehensive, intensive family treatment, 8- 9 of families involved in child mal treatment may be rehabilitated to provide adequate care for their children.
EMOTIONAL ABUSE AND NEGLECTSUGGESTIVE PHYSICAL FINDINGS – Failure to thrive. Feeding disorders, such as rumination EnuresisSUGGESTIVE BEHAVIORS – Self-stimulatory behavior such as biting, rocking. During infancy, lack of social smile and stranger anxiety. Withdrawal Unusual fearful ness Antisocial behavior, such as destructiveness, stealing, cruelty Lags in emotional and intellectual development, especially language Suicide attempts.
SEXUAL ABUSE Sexual abuse includes any activity with a child, before the age of legal consent that is for the sexual gratification of an adult or a significantly older child. Sexual abuse includes oral - genital, genital - genital, genital - recta l, hand - genital, hand - recta l or hand breast contact; exposure of sexual anatomy, forced viewing of sexual anatomy; and showing of pornography to a child or using a child in the production of pornography.
DEFINITIONS – SEXUAL PLAY – The other hand may be defined as viewing or touching of the genitals, buttocks or chest by pre adolescent children 4 separated by not more than 4 years, in which these has been no force or coercion. INCEST – Any physical sexual activity between family members; alone relationship is not required causes can include step parents, upper siblings, grand parents, aunts and uncles does not include sexual relations between legally sanctioned parents such as spouses. E.g. Brother-sister. MOLESTATION – A vague term that includes “indecent liberties”, such as touching, foundling, kissing, single or mutual masturbations, or oral- genital contact.
CONT…….. EXHIBITIONISM – Indecent exposure, usually exposure of the genitals by an adult to children or other adults. CHILD PORNOGRAPHY – Arranging and photographing in any media sexual acts involving children, either alone or with adults or animals, regardless of consent by the childs legal guardian; also may denote distribution of such material in any form with or with out profit. CHILD PROSTITUTION – Involving children in sex acts for profit and usually with changing partners. PEDOPHILIA – Laterally means “Love of child” and does not denote a type of sexual activity but the preference for pre pubertal children as the means of achieving sexual excitement.
ETIOLOGY/ METHODS – Gifts or privileges. Misrepresents moral standards by telling the child that it is okay’ Emotionally and socially impoverished children Sex offender pressures the victim into secrecy regarding the activity by describing it as a secret between us. Childs fears Vulnerable children
CLINICAL MANIFESTATONSSUGGESTIVE PHYSICAL FINDINGS – Bruises bleeding, lacerations or irritation of external genitalia, anus, mouth or throat Torn, stained or bloody under clothing Pain on urination or pain, swelling and itching of genital area Penile discharge Sexually transmitted disease, non specific vaginitis or venereal warts Difficulty in walking or sitting Pregnancy in young adolescent Recurrent urinary tract infection
SUGGESTIVE BEHAVIORS Sudden emergence of sexually related problems, including excessive or public masturbation, age - in appropriate sexual play, promiscuity or overtly seductive behavior. With drawn, excessive day dreaming Poor relationships with peers Preoccupied with fantasies, especially in play Regressive behavior, such as bed- wetting or thumb – sucking Sudden onset of phobias or fears, particularly fears of the dark, men, strangers or particular settings or situations (e.g. Undue fear of leaving the house). Running away from house - Substance abuse - Rapidly declining school performance Suicidal attempts or ideation.
INVESTIGATION –Investigating the possibility of sexual abuse requires supportive sensitive and detailed history taking. History Taking Physical Examination Laboratory Findings- It depends on the history and the time since injury. Specimens of offender blood, hair and the victims mail clipping and clothing. Gonorrhea and chlamydia cultures should be obtained from the mouth, anus and genitals. In the vagina, motile sperm can be found for 6 hr non motile sperm exist for longer than 72 hrs.
TREATMENT – It is a criminal offense and is investigated by the police All victims of sexual abuse require psychological support. The consequences and appropriate therapy of sexual abuse vary, depending on the type of abuse; the age and other physical and emotional factors in the victim. The therapist may recommend that the victim of incest be returned home he the perpetrator is out of the home. Medication to prevent pregnancy may be given to post menarchal girls with in the previous 72 hr intercourse. Treatment with antibiotics is initiated to prevent sexually transmitted diseases. The offending parents and spouse should be referred for psychiatric or psychologic evaluation.
NURSING CARE OF SEXUALLY ABUSED CHILDREN Nurse must be aware of the presenting symptoms that frequently mask sexual abuse (abdominal pain, somatic complaints with no identifiable cause). Nurse must be able to support a patient / after disclosure. The nurse who understands the investigative assessment procedure will be able to judge. Nurse suggestions about age – appropriate ways to gather data can be valuable to the interviewer. The nurse provides support to the patient and family and to record accurately child behavior and child – parent interactions.
PREVENTION – The primary prevention of sexual abuse is related, in part, to normal developmental education and sexual behavior. Teaching children the proper names of all body parts, including the names, function and significance of private parts nipples, genitals and rectum Teach to children should be say NO. Victim therapy should decrease the potential for re- abuse. Routine family discussions of uncomfortable events. Written permission should be obtained from any caregiver to allow a police screening for offenses.
PROGNOSIS – With early and adequate intervention, victims may lead normal adult lives. However, even with intervention, certain adolescent victims may run away from home and fall to adolescent prostitution, violence, drug addiction and unprepared parenthood. Others who remain at home may manifest a variety of emotional problems, including depression, suicidal gestures, deterioration in school performance and conversion reactions.
NURSING ROLES IN PREVENTION OF CHILD ABUSEThe nursing role in prevention of child abuse and maltreatment is addressed here by using 5 objectives as a framework – Increase public awareness of the nature and extent of efforts to prevent child abuse. Increase knowledge of health professionals. Coordinate and improve the availability, accessibility and quality of health services to families. a. Advocacy for expanded health and social services for children and families. b. Identification and treatment of families at high risk for child abuse and maltreatment. Develop data systems to monitor the incidence and prevalence of all forms of child abuse. Research.
NURSING DIAGNOSIS – Fear / anxiety related to negative interpersonal interaction, repeated maltreatment, powerlessness, potential loss of parents. Impaired parenting related to child, caregiver or situational characteristics that precipitate abusive behavior. Risk for trauma related to characteristics of child, caregiver and environment. Deficient knowledge about the child’s realistic developmental abilities how to access external support resources related to past inexperience with parenting.
OTHER NSG DIAGNOSIS – Pain related to inflicted injury. Impaired skin integrity relate to inflicted injuries. Altered nutrition less than body requirements related to inadequate caloric intake.