Critical Care- Child Maltreatment

Inaction with substance abuse

turning a blind eye to the teenager who is abusing drugs, and alcohol

Why do abused children act like loners?

1. Because they feel like they don't belong or are unworthy 2. Teenagers may seek inappropriate relationships to have their needs met, or may have difficulty trusting others

Avoidance

moving away from adjustments (i.e., denial in the face of evidence, refusal of treatment, Angry at others, suicidial thoughts, drug/alcohol use)

Approach

moving towards adjustment (i.e., Asking for info and help, sharing burden, able to express their feelings, realistic expectations) Being able to anticipate future problems and seek guidence and answers to problems.

Two categories of action

physical and emotional neglect

Aspects of normalization

preparation, participation, sharing, control, expectations, positive attitude

Family-centered care

1) Assess and capitalize on family strengths 2) Foster families confidence in the child's care 3) Empower the family to become advocates for the child

Managed care

1) Reduce barriers to care and services 2) Improve quality of services 3) Improve education of family, community, and health care professionals 4) Increase community services...nurses become networkers

What are the 2 different reactions to children's neglect or maltreatment?

1. Fight back: aggressive and model the behavior the get to others...pets...peers at school 2. Self-destructive: withdrawn, or suicidal

Methods of coercion

1. Gifts/privileges are offered or withheld 2. Adult misrepresents moral standards by telling the child that it is "okay to do" 3. Provides needy child with warmth/human contact 4. Stresses secrecy 5. Offender exploits child's fear of abandonment or rejection

Emotional maltreatment

1. Ignoring the child verbally assaulting the child, Name calling, etc. "you stupid kid!"..."you never do anything right!"..." I wish you'd never been born" 2. Terrorizing the child by threatening their harm, forcing them to watch horror movies, deliberate actions to impair the child's self-esteem( like isolating them from normal social activities)

Primary factors that contribute to child neglect

1. Lack of Education (parents don't know what the child needs) 2. Resources (lack of funds) 3. Caregivers with a substance abuse problem

Developmental focus

Assess their baseline developmental level for the condition they have, not their age

Shaken Baby Syndrome anatomy

Babies have large heads and weak neck muscles. If a baby is forcefully shaken, his or her fragile brain moves back and forth inside the skull. This causes bruising, swelling and bleeding in the subdural spaces.

Mainstreaming

Getting these kids a social life. Integrating them with normal kids or being able to be around other kids like them. [Individualized Educational Plan..IEP] nurses can help contribute to their abilities.

Major goal of the family

support family coping and functioning

Coping mechanisms

approach and avoidance

Child risk factors for child maltreatment

birth to 1 year old, children that are demanding physically and emotionally i.e., hyperactive, mentally or physically handicap)

Environmental risk factors for child maltreatment

chronic stressors in the home such as parental drug/alcohol abuse, divorce, poverty

Inaction with delinquency

city officials are beginning to hold the parents responsible

Testing

Seeking way out of depression

Period

The crying has a beginning and an end

Initiation and Perpetuation of Sexual Abuse

1. Starts insidiously (unless it involves an isolated attack, such as rape) 2. Perpetrator gains trust 3. Coerced in various ways 4. Child becomes afraid to tell 5. Child fears it's their fault or have limited vocabulary

The effects of child sexual abuse by a family member is what?

A form of incest, and can result in more serious and long-term psychological trauma, especially in the case of parental incest

Who is the typical abuser?

A male that the victim knows; family victims make up 2/3 of the abusers

Nursing assessment for school age children

Also have the UTI's/yeast infections redness in the genital perineal area, but may ahve bilateral bruises easily covered in areas if they were restrained

Adjustment

Anger is a part of the adjustment phase too, people are comfortable with taking things out on staff, we can be helpful in maintaining our cool and having the awareness of the process they are going through and not take it personally.

Characteristics of abusers

Anyone and anywhere

Sexual abuse

Below the age of consent; it doesn't matter what the child says, adults still do not have the legal right to grant consent for sex

Adolescence: 12 to 18 Years

Ego Development Outcome: Identity vs. Role Confusion Basic Strengths: Devotion and Fidelity *Up to this stage, according to Erikson, development mostly depends upon what is done to us. From here on out, development depends primarily upon what we do

School Age: 6 to 12 Years

Ego Development Outcome: Industry vs. Inferiority Basic Strengths: Method and Competence

Play Age: 3 to 5 Years

Ego Development Outcome: Initiative vs. Guilt Basic Strength: Purpose

Infancy: Birth to 18 Months

Ego Development Outcome: Trust vs. Mistrust Basic strength: Drive and Hope

Sexual abuse definition

Defined as "the use, persuasion, or coercion of any child to engage in sexually explicit conduct (or any simulation of such conduct) or producing visual depiction of such conduct, or rape, molestation, prostitution, or incest with children

Physical Abuse

Deliberate physical harm that occurs across all socioeconomic, religious, cultural, racial and ethnic groups

Older children and adolescents may exhibit what?

Depression/Anxiety/fear, nightmares or sleep disturbances, poor school performance, unhealthy behaviors to hide painful emotions (promiscuity, substance abuse, eating disorders, aggression), poor body image, running away from home

Physical neglect

Deprived of necessary things: food, water, shelter, supervision; parents MUST provide these to children

Risk factors for older children that are maltreated

Early pregnancy or marriage, suicidal gestures, anger about being forced into situations beyond one's control, difficulty setting safe limits with others (ex: saying no to people") and relationship problems

Early Childhood: 18 Months to 3 Years

Ego Development Outcome: Autonomy vs. Shame Basic Strengths: Self-control, Courage, and Will

Normalization

Establishing a normal pattern

Neglect

Failure to provide basic needs for the child; not having what you need to physically survive such as food, water, shelter

Clinical signs of child maltreatment

Failure to thrive Concentration and learning problems Low self-esteem Depression School abstances Poor health Pallor Bad breath, body odor, dirty Constant hunger and stealing money/food Aggressive behaviors Eating disorders

Children ages 4 to 9 may exhibit what?

Fear of particular people, places or activities, regression to earlier behaviors such as bed wetting or stranger anxiety, victimization of others, feelings of shame or guilt, nightmares or sleep disturbances, withdrawal from family or friends, fear of attack recurring, eating disturbances

Children up to 3 may exhibit what?

Fear or excessive crying, vomiting, feeding problems, bowel problems, sleep disturbances, failure to thrive

Risk factors for child abuse have been identified where?

In the parent, child, and environment

Acknowledgement

Is really about acceptance. The parent/family seems to have taken a deep breath and begins the lifelong process of just dealing with approaching whats next. Occasionally expect during crisis a relapse into the grief process

Inaction

Lack of intervention

Psychological maltreatment

Parent abuses or destorys their pet in front of them or destroys their property

Nursing Interventions for Shaken Baby Syndrome

Parental and Caregiver Education --> we can let the parents know what to expect they can be prepared to cope with it

Emotional neglect

Parents don't know emotional nurturing (affection and attention) is essential to normal growth and development; sometimes postpartum depression can cause a lack of a bond to form, therefore disconnecting emotionally from the relationship

Pattern

Pay attention to the incompatibility between the history and the injury. Are they congruent? Does the event match the injury? Also observe interaction between child and family, is it normal?

P.U.R.P.L.E.

Peak of crying: 3-4 months Unexpected: comes unexpectedly Resists Soothing Pain-like face Long lasting: cries up to 3 hours Evening: crying clusters in evenings

Ultimate goal of nursing care for child maltreatment

Prevention 1. Teach positive parenting skills: good communication, appropriate discipline, responding to child's needs, cultural differences 2. Provide social support: set them up with social services and community organizations

Last result of trying to stop the baby crying

Put the infant in a safe place for 5-10 minutes and ask others for help

Nursing assessment for children maltreatment

STD's/yeast infections/UTI's *Redness or soreness around their private areas may be a good indicator that something is wrong. Remember that redness in these areas can be from diaper rashes too.

Stages of grief

Shock Denial Anger Bargaining Depression Testing Acceptance

Common sources of stress within the family

Siblings needs, marital problems, financial strain, social isolation, demands of required care of the disabled child all contribute to ongoing or emerging stress in addition to what the family has been able to adjust to. Our role becomes emotional support, providing information and referral to access support.

Results of Shaken Baby Syndrome

Subdural/subarachnoid hemorrhages Seizures Blindness Hearing loss Cerebral palsy

When children report a experiencing abuse, what should you do?

Take them seriously and cautiously

Emotional Abuse

Telling someone they are stupid, retarded, no good, etc.; emotional scars can last a lifetime and people begin to adopt what you tell them as the truth

Early intervention

Time period of birth to 3 years nurses can help in coordinating services for the child and family. Providing direction.

Child maltreatment

Umbrella term that includes all types of abuse and neglect of children under 18; can be by a parent, caregiver or anyone else in a custodial role (clergy, teachers, coaches) *One of the most significant social problems affecting children

Risk factors for sexual abuse

Unavailable parent Lack of emotional closeness and flexibility Social isolation Emotional deprivation Communication difficulties

Shaken Baby Syndrome

Usually occurs when a parent or caregiver severely shakes a baby or toddler due to frustration or anger, often because the child won't stop crying; 37% of parents don't know what to do and 90% of caregivers don't know what to do.

Acceptance

Will occur in stages, experienced initially as a crisis. Nurses can provide emotional support initially in a non-judgemental manner during each phase, because initial reactions are individualized and occur in varying degrees

Parental risk factors for child maltreatment

Young Single Low-income Uneducated Substance abuse Abused themselves *these factors have been shown to lead to stress of the parent and their ability to poorly manage themselves builds to a point where they essentially lash out at the child *In addition, the those who abuse, have a history of child abuse in their history in about 1/3rd of the cases