MENTAL HEALTH: CHAPTER 12: ABUSE & VIOLENCE

Types Of Child Abuse: Physiological Abuse:

- (emotional abuse) includes verbal assaults, such as blaming, screaming, name-calling, and using sarcasm; constant family discord characterized by fighting, yelling, and chaos; and emotional deprivation or withholding of affection, nurturing, and normal experiences that engender acceptance, love, security, and self-worth. - Emotional abuse often accompanies other types of abuse (e.g., physical or sexual abuse). - Exposure to parental alcoholism, drug use, or prostitution—and the neglect that results—also falls within this category.

Abusers:

- Abusers not only exerts physical power, but also social and economic control (for families)

Cultural Consideration:

- Although domestic violence affects families of all ethnicities, races, ages, national origins, sexual orientations, religions, and socioeconomic backgrounds, a specific population is particularly at risk: immigrant women. - Battered immigrant women face legal, social, and economic problems different from the U.S. citizens who are battered and from people of other cultural, racial, and ethnic origins who are not battered. •The battered woman may come from a culture that accepts domestic violence. •She may believe she has less access to legal and social services than do the U.S. citizens. •If she is not a citizen, she may be forced to leave the United States if she seeks legal sanctions against her abuser or attempts to leave him or her. •She is isolated by cultural dynamics that do not permit her to leave her abuser; economically, she may be unable to gather the resources to leave, work, or go to school. •Language barriers may interfere with her ability to call 911; learn about her rights or legal options; and obtain shelter, financial assistance, or food. - It may be necessary for the nurse to obtain the assistance of an interpreter whom the woman trusts, make referrals to legal services, and assist the woman with contacting the Department of Immigration to deal with these additional concerns.

Abuser & Alcohol:

- An abusive person is likely to use alcohol and drugs but this is not a cause-and-effect relationship

Child Abuse: Assessment:

- As with all types of family violence, detection and accurate identification are the first steps. - Burns or scalds may have an identifiable shape, such as cigarette marks, or may have a "stocking and glove" distribution, indicating scalding. - The parent of an infant with a severe skull fracture may report that he or she "rolled off the couch," even though the child is too young to do so or the injury is much too severe for such a shortfall. - Bruises may have familiar, recognizable shapes such as belt buckles or teeth marks. - Children who have been sexually abused may have urinary tract infections; bruised, red, or swollen genitalia; tears of the rectum or vagina; and bruising. - The emotional response of these children varies widely. - Often, these children talk or behave in ways that indicate more advanced knowledge of sexual issues than would be expected for their ages. - At other times, they are frightened and anxious and may either cling to an adult or reject adult attention entirely. - The key is to recognize when the child's behavior is outside what is normally expected for his or her age and developmental stage. - Seemingly unexplained behavior, from refusal to eat to aggressive behavior with peers, may indicate abuse. - The nurse does not have to decide with certainty that abuse has occurred. - Nurses are responsible for reporting suspected child abuse with accurate and thorough documentation of assessment data. - All 50 states have laws, often called mandatory reporting laws, that require nurses to report suspected abuse. - The nurse alone or in consultation with other health team members (e.g., physicians or social workers) may report suspected abuse to appropriate local governmental authorities. - In some states, that authority is Child Protective Services, Children and Family Services, or the Department of Health. - The number to call can be located in the local telephone book. - The reporting person may remain anonymous if desired. - People who work in such agencies have special education in the investigation of abuse. - Questions must be asked in ways that do not further traumatize the child or impede any possible legal actions. - The generalist nurse should not pursue investigation with the child; it may do more harm than good.

Touching Survivors:

- Ask for permission to touch survivors for any reason

Intimate Partner Violence: Clinical Picture:

- Because abuse is often perpetrated by a husband against a wife, that example is used in this section. - These same patterns are consistent, however, between partners who are not married, between same-sex partners, and with wives who abuse their husbands. - An abusive husband often believes his wife belongs to him (like property) and becomes increasingly violent and abusive if she shows any sign of independence, such as getting a job or threatening to leave. - Typically, the abuser has strong feelings of inadequacy and low self-esteem as well as poor problem-solving and social skills. - He is emotionally immature, needy, irrationally jealous, and possessive. - He may even be jealous of his wife's attention to their own children or may beat both his children and his wife. - By bullying and physically punishing the family, the abuser often experiences a sense of power and control, a feeling that eludes him outside the home. - Therefore, the violent behavior is often rewarding and boosts his self-esteem. - Dependency is the trait most commonly found in abused wives who stay with their husbands. - Women often cite personal and financial dependency as reasons why they find leaving an abusive relationship extremely difficult. - Regardless of the victim's talents or abilities, she perceives herself as unable to function without her husband. - She also often suffers from low self-esteem and defines her success as a person by her ability to remain loyal to her marriage and "make it work." - Some women internalize the criticism they receive and mistakenly believe they are to blame. - Women also fear their abusers will kill them if they try to leave. - This fear is realistic, given that national statistics show that women have a much greater chance of being murdered when leaving an abusive relationship than if they stay.

Intimate Partner Violence: Assessment:

- Because most abused women do not seek direct help for the problem, nurses must help identify abused women in various settings. - Nurses may encounter abused women in emergency departments, clinics, or pediatricians' offices. - Some victims may be seeking treatment for other medical conditions not directly related to the abuse or for pregnancy. - Identifying abused women who need assistance is a top priority of the Department of Health and Human Services. - The generalist nurse is not expected to deal with this complicated problem alone. - He or she can, however, make referrals and contact appropriate health care professionals experienced in working with abused women. - Above all, the nurse can offer caring and support throughout the victim's visit. - It is essential to ask everyone whether they are safe at home or in their relationship. - If the nurse asks only people seen as "likely victims," he or she will be stereotyping and may well miss someone who really needs help. - Many hospitals, clinics, and doctors' offices ask women about safety issues as part of all health histories or intake interviews. - Because this issue is delicate and sensitive and many abused women are afraid or embarrassed to admit the problem, nurses must be skilled in asking appropriate questions about abuse. - The initial questions are designed to detect abuse. - The nurse should ask the latter questions if warranted. - He or she should ask these questions when the woman is alone; the nurse can paraphrase or edit the questions as needed for any given situation.

Community Violence: Bullying:

- Bullying is another problem experienced at school, including verbal aggression; physical acts from shoving to breaking bones; targeting a student to be shunned or ignored by others; and cyberbullying involving unwanted e-mails, text messages, or pictures posted on the internet. - Adolescent suicide, substance use, self-harm ideation and actions, and moderate-to-severe symptoms of depression are correlated with bullying.

Date Rape:

- Can happen on first date, ride home from party, or 2 people who have known each other for some time

Elderly Abuse: Assessment:

- Careful assessment of elderly persons and their caregiving relationships is essential in detecting elder abuse. - Often, determining whether the elder's condition results from deterioration associated with a chronic illness or from abuse is difficult. - Several potential indicators of abuse require further assessment and careful evaluation - These indicators by themselves, however, do not necessarily signify abuse or neglect. - The nurse should suspect abuse if injuries have been hidden or untreated or are incompatible with the explanation provided. - Such injuries can include cuts, lacerations, puncture wounds, bruises, welts, or burns. - Burns can be cigarette burns, scaldings, acid or caustic burns, or friction burns of the wrists or ankles caused from being restrained by ropes, clothing, or chains. - Signs of physical neglect include a pervasive smell of urine or feces, dirt, rashes, sores, lice, or inadequate clothing. - Dehydration or malnourishment not linked with a specific illness also strongly indicates abuse. - Possible indicators of emotional or psychological abuse include an elder who is hesitant to talk openly to the nurse or who is fearful, withdrawn, depressed, and helpless. - The elder may also exhibit anger or agitation for no apparent reason. - He or she may deny any problems, even when the facts indicate otherwise. - Possible indicators of self-neglect include inability to manage money (hoarding or squandering while failing to pay bills), inability to perform activities of daily living (personal care, shopping, food preparation, and cleaning), and changes in intellectual function (confusion, disorientation, inappropriate responses, and memory loss and isolation). - Other indicators of self-neglect include signs of malnutrition or dehydration, rashes or sores on the body, an odor of urine or feces, or failure to keep necessary medical appointments. - For self-neglect to be diagnosed, the elder must be evaluated as unable to manage day-to-day life and take care of him or herself. - Self-neglect cannot be established solely on the basis of family members' beliefs that the elder cannot manage his or her finances. - For example, an older adult cannot be considered to have self-neglect just because he or she gives away large sums of money to a group or charity or invests in some venture of which family members disapprove. - Warnings of financial exploitation or abuse may include numerous unpaid bills (when the client has enough money to pay them), unusual activity in bank accounts, checks signed by someone other than the elder, or recent changes in a will or power of attorney when the elder cannot make such decisions. - The elder may lack amenities that he or she can afford, such as clothing, personal products, or a television. - The elder may report losing valuable possessions and report that he or she has no contact with friends or relatives. - The nurse may also detect possible indicators of abuse from the caregiver. - The caregiver may complain about how difficult caring for the elder is, incontinence, difficulties in feeding, or excessive costs of medication. - He or she may display anger or indifference toward the elder and try to keep the nurse from talking with the elder alone. - Elder abuse is more likely when the caregiver has a history of family violence or alcohol or drug problems. - All 50 states, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands have laws governing adult protective services. - These cover elder citizens and, in most states, include adults who are considered dependent, disabled, or impaired and who must rely on others to meet basic needs. - These laws provide a system for defining, reporting, and investigating abuse, as well as providing services to victims. - However, abuse reporting for elders or dependent adults is not mandatory in all states and territories. - Nurses should be familiar with the laws or statutes for reporting abuse in their own states. - Many cases remain unreported. - The local agency on aging can provide procedures for reporting abuse in accordance with state laws. - To find a local agency, go online and enter adult protective services to be directed to local addresses and phone numbers in the area where you want to report.

Cycle Of Violence:

- Cycle repeats itself - Over time, violent episodes are more frequent and period of remorse can disappear altogether

Dependency & Abuse:

- Dependency is a common trait found in abused wives who stayed with their husbands

Elderly Abuse: Treatment & Intervention:

- Elder abuse may develop gradually as the burden of care exceeds the caregiver's physical or emotional resources. - Relieving the caregiver's stress and providing additional resources may help correct the abusive situation and leave the caregiving relationship intact. - In other cases, the neglect or abuse is intentional and designed to provide personal gain to the caregiver, such as access to the victim's financial resources. - In these situations, removal of the elder or caregiver is necessary.

Psychological Abuse =

- Emotional abuse

Family Violence:

- Encompasses spouse battering; neglect and physical, emotional, or sexual abuse of children; elder abuse; and marital rape. - In many cases, family members tolerate abusive and violent behavior from relatives they would never accept from strangers. - In violent families, the home, which is normally a safe haven of love and protection, may be the most dangerous place for victims. - Research studies have identified some common characteristics of violent families regardless of the type of abuse that exists.

Intimate Partner Violence: Treatment & Intervention:

- Every state in the United States allows police to make arrests in cases of domestic violence; more than half of the states have laws requiring police to make arrests for at least some domestic violence crimes. - Sometimes after police have been called to the scene, the abuser is allowed to remain at home after talking with police and calming down. - If an arrest is made, sometimes the abuser is held only for a few hours or overnight. - Often, the abuser retaliates upon release; hence, women have a legitimate fear of calling the police. Studies have shown that arresting the batterer may reduce short-term violence but may increase long-term violence. - A woman can obtain a restraining order (protection order) from her county of residence that legally prohibits the abuser from approaching or contacting her. - Nevertheless, a restraining order provides only limited protection. - The abuser may decide to violate the order and severely injure or kill the woman before police can intervene. - Some states have enacted laws removing firearms from persons identified on a protection order. - However, informing the person of the firearm ban or collecting the firearm is an ambiguous process in some states - Civil orders of protection are more effective in preventing future violence when linked with other interventions such as advocacy counseling, shelter, or talking with health care providers. - Women who left their abusive relationships are more likely to be successful if their legal and psychological needs are addressed simultaneously. - Even after a victim of battering has "ended" the relationship, problems may continue. - Stalking, or repeated and persistent attempts to impose unwanted communication or contact on another person, is a problem. - In addition to abusive partner stalking when the end of the relationship is not accepted, other stalkers are "would-be lovers," pursuing relationships that have never even existed, doctors stalked by patients, or famous people stalked by "fans." - Lifetime prevalence rates of stalking are one in six women and one in 19 men. - Among college students, 12% to 13% reported being the victim of a stalker - Cyberstalking can be monitoring, following, or intruding into another's social media, using a false identity to get back into the person's life, or tracking his or her location with a cell phone. - These have all become more common in recent years, and it has become more difficult to detect the stalker - Battered women's shelters can provide temporary housing and food for abused women and their children when they decide to leave the abusive relationship. - In many cities, however, shelters are crowded; some have waiting lists, and the relief they provide is temporary. - The woman leaving an abusive relationship may have no financial support and limited job skills or experience. Often, she has dependent children. -These barriers are difficult to overcome, and public or private assistance is limited. - In addition to the many physical injuries that abused women may experience, there are emotional and psychological consequences. - Individual psychotherapy or counseling, group therapy, or support and self-help groups can help abused women deal with their trauma and begin to build new, healthier relationships. - Battering may also result in PTSD

Community Violence: Effects On Children/Young Adults:

- Exposure to community violence tremendously affects children and young adults. - When children witness violence, they experience stress-related symptoms that increase with the amount of violence they see. - In addition, witnessing violence can lead to future problems with aggression, depression, relationships, achievement, and abuse of drugs and alcohol. - Addressing the problem of violence exposure may help alleviate the cycle of dysfunction and further violence.

Family Violence Pattern:

- Family violence is a learned pattern of behavior

Community Violence: Ostracism:

- Ignoring and excluding a target individual, has recently emerged as one of the more common and damaging forms of bullying. - The victim experiences threats to belonging, self-esteem, meaningful existence, and sense of control. - Ostracism may pose an even greater threat to children's adjustment than bullying - Nearly one-third of the U.S. students report they experience bullying, either as a target or as a perpetrator. - The frequency of bullying was highest among sixth through eighth graders. - Children who were bullied reported more loneliness and difficulty making friends, and those who bullied were more likely to have poor grades and use alcohol and tobacco. - Children with special physical health care needs are bullied more often, and children with chronic emotional, behavioral, or developmental problems are more likely to be victims of bullying

Immigrant Women & Abuse:

- Immigrant women more at risk for domestic violence b/c they may come from a culture that accepts it - BELIEVE to have less access to services compared to U.S citizens - May be forced to leave U.S if provoked sanctions against husband - Isolated by cultural dynamics that don't permit her to leave husband - Have language barriers

Family Members In Abuse:

- In many cases, family members tolerate abuse/violent behavior from relatives they would never accept from strangers

Types Of Child Abuse: Sexual Abuse:

- Involves sexual acts performed by an adult on a child younger than 18 years. - Examples include incest, rape, and sodomy performed directly by the person or with an object, oral-genital contact, and acts of molestation such as rubbing, fondling, or exposing the adult's genitals. - Sexual abuse may consist of a single incident or multiple episodes over a protracted period. - A second type of sexual abuse involves exploitation, such as making, promoting, or selling pornography involving minors, and coercion of minors to participate in obscene acts.

Types Of Child Abuse: Neglect:

- Is malicious or ignorant withholding of physical, emotional, or educational necessities for the child's well-being. - Child abuse by neglect is the most prevalent type of maltreatment and includes refusal to seek health care or delay doing so; abandonment; inadequate supervision; reckless disregard for the child's safety; punitive, exploitive, or abusive emotional treatment; spousal abuse in the child's presence; giving the child permission to be truant; or failing to enroll the child in school.

Elder Abuse:

- Is the maltreatment of older adults by family members or others in a caregiver role. - It may include physical and sexual abuse, psychological abuse, neglect, self-neglect, financial exploitation, and denial of adequate medical treatment. - It is estimated that one in 10 people over age 65 are injured, exploited, abused, or neglected by their caregivers, but few elder maltreatment cases are reported. - Perpetrators of the abuse are most likely living with the victim and/or related to the victim as well as having legal or psychological problems themselves. - Most victims of elder abuse are 75 years or older; 60% to 65% are women. - Abuse is more likely when the elder has multiple chronic mental and physical health problems and when he or she is dependent on others for food, medical care, and various activities of daily living - Persons who abuse elders are almost always in a caregiver role, or the elders depend on them in some way. - Most cases of elder abuse occur when one older spouse is taking care of another. - This type of spousal abuse usually happens over many years after a disability renders the abused spouse unable to care for him or herself. - When the abuser is an adult child, it is twice as likely to be a son as a daughter. - A psychiatric disorder or a problem with substance abuse may aggravate abuse of elders. - Bullying has also been identified in senior living facilities between residents. - Verbal and social bullying is most common. - Both victims and perpetrators were reported having cognitive and physical disabilities - Educational programs on safe interventions for bullying between residents are indicated. - Elders are often reluctant to report abuse, even when they can, because the abuse usually involves family members whom the elder wishes to protect. - Victims also often fear losing their support and being moved to an institution. - No national estimates of abuse of elders living in institutions are available. - However, under a 1978 federal mandate, ombudsmen are allowed to visit nursing homes to check on the care of the elderly. - These ombudsmen report that complaints of elder abuse are common in institutions, though not all complaints are substantiated.

Intimate Partner Violence:

- Is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship. - The relationship may be spousal, between partners, boyfriend, girlfriend, or an estranged relationship. - The abuse can be emotional or psychological, physical, sexual, or a combination (which is common). Psychological abuse (emotional abuse) includes name-calling, belittling, screaming, yelling, destroying property, and making threats as well as subtler forms, such as refusing to speak to or ignoring the victim. - Physical abuse ranges from shoving and pushing to severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, and even homicide. - Sexual abuse includes assaults during sexual relations such as biting nipples, pulling hair, slapping and hitting, and rape - Nearly one in four women and one in seven men report having experienced severe physical violence from an intimate partner in their lifetimes in the United States. - About one in six women and one in 14 men have experienced sexual violence by an intimate partner - Pregnant women experience an increase in violence during pregnancy. - Battering during pregnancy leads to adverse outcomes, such as miscarriage and stillbirth, as well as further physical and psychological problems for the woman. - The increase in violence often results from the partner's jealousy, possessiveness, insecurity, and lessened physical and emotional availability of the pregnant woman - Domestic violence occurs in same-sex relationships with the same statistical frequency as in heterosexual relationships. - Although same-sex battering mirrors heterosexual battering in prevalence, its victims receive fewer protections. - Seven states define domestic violence in a way that excludes same-sex victims. - Twelve states have sodomy laws that designate sodomy (anal intercourse) as a crime, even though such laws were invalidated by the Supreme Court in 2003. - The same-sex batterer has an additional weapon to use against the victim: the threat of revealing the partner's homosexuality to friends, family, employers, or the community.

Children Of Abuse:

- More likely to miss school, less likely to attend college, continue to have problems through adolescence to adulthood

Most Abuse Occurs...

- Most abuse occurs by someone the victim knows

Self-Awareness Issues:

- Nurses are sometimes reluctant to ask women about abuse, partly because they may believe some common myths about abuse. - They may believe that questions about abuse will offend the client or fear that incorrect interventions will worsen the situation. - Nurses may even believe that a woman who stays in an abusive relationship might deserve or enjoy the abuse or that abuse between husband and wife is private. - Some nurses may believe abuse to be a societal or legal, not a health, problem. - Listening to stories of family violence or rape is difficult; the nurse may feel horror or revulsion. - Because clients often watch for the nurse's reaction, containing these feelings and focusing on the client's needs are important. - The nurse must be prepared to listen to the client's story, no matter how disturbing, and support and validate the client's feelings with comments such as "That must have been terrifying" or "Sounds like you were afraid for your life." - The nurse must convey acceptance and regard for the client as a person with worth and dignity regardless of the circumstances. - These clients often have low self-esteem and guilt. - They must learn to accept and face what has occurred. - If the client believes that the nurse can accept him or her after hearing what has happened, he or she then may gain self-acceptance. - Although this acceptance is often painful, it is essential to healing. - The nurse must remember that he or she cannot fix or change things; the nurse's role is to listen and convey acceptance and support for the client. - Nurses with personal histories of abuse or trauma must seek professional assistance to deal with these issues before working with survivors of trauma or abuse. - Such nurses can be effective and supportive of other survivors but only after engaging in therapeutic work and accepting and understanding their own trauma.

Dynamics Of Rape:

- Of men who commit rape, 50% are age 30 and older; 25% are between 21 and 29. - In terms of race, 57% are white. Alcohol is involved in 34% of cases. - Rape often accompanies another crime. - Almost 75% of arrested rapists have prior criminal histories, including other rapes, assaults, robberies, and homicides - In the past, rape and its perpetrators were described in terms of motivation or dynamics (e.g., power, anger, opportunity). - Those categories weren't particularly useful since they were designed around the "rape by a stranger" idea, which is not usually the circumstance. - It is generally accepted that rape is not a sexual crime but rather the perpetrator's exertion of power, control, infliction of pain, or punishment for perceived wrongs. - Feminist theory proposes that women have historically served as objects of aggression, dating back to when women (and children) were legally the property of men. - In 1982, for the first time, a married man was convicted of raping his wife, signaling the end of the notion that sexual intercourse could not be denied in the context of marriage. - Women who are raped are frequently in life-threatening situations, so their primary motivation is to stay alive. - At times, attempts to resist or fight the attacker succeed; in other situations, fighting and yelling result in more severe physical injuries or even death. - Degree of submission is higher when the attacker has a weapon such as a gun or knife. - In addition to forcible penetration, the more violent rapist may urinate or defecate on the woman or insert foreign objects into her vagina and rectum. - The physical and psychological trauma that rape victims suffer is severe. - Related medical problems can include acute injury, sexually transmitted diseases, pregnancy, and lingering medical complaints. - A cross-sectional study of medical patients found that women who had been raped rated themselves as significantly less healthy, visited a physician twice as often, and incurred medical costs more than twice as high as women who had not experienced any criminal victimization. - The level of violence experienced during the assault was found to be a powerful predictor of future use of medical services. - Many victims of rape experience fear, helplessness, shock, disbelief, guilt, humiliation, and embarrassment. - They may also avoid the place or circumstances of the rape; give up previously pleasurable activities; experience depression, anxiety, PTSD, sexual dysfunction, insomnia, and impaired memory; or contemplate suicide - Until recently, the rights of rape victims were often ignored. - For example, when rape victims reported a rape to authorities, they often faced doubt and embarrassing questions from police officers. - The courts did not protect the rights of victims; for example, a woman's past sexual behavior was admissible in court even though the past criminal record of her accused attacker was not. - Laws to correct these problems have been enacted on a state-by-state basis since the mid-1980s and continue to be enacted. - Although the treatment of rape victims and the prosecution of rapists have improved in the past two decades, many people still believe that a woman provokes rape with her behavior and that the woman is partially responsible for this crime.

Community Violence: Violence On Larger Scale/PTSD:

- On a larger scale, violence such as the terrorist attacks in New York, Washington, and Pennsylvania in 2001 also has far-reaching effects on citizens. - In the immediate aftermath, children were afraid to go to school or have their parents leave them for any reason. -Adults had difficulty going to work, leaving their homes, using public transportation, and flying. - One year later, one in 10 New York area residents suffered lingering stress and depression as a result of September 11, and an additional 532,240 cases of PTSD had been reported in the New York City metropolitan area alone. - In addition, people reported higher relapse rates of depression and anxiety disorders. - There was no increase in PTSD nationwide as a result of individuals watching the attacks and associated coverage on television, however, which had been an initial concern. - Prevalence rates of PTSD and depression remain elevated 15 years later - Early intervention and treatment are key to dealing with victims of violence. - After several instances of school or workplace shootings, counseling, referrals, and ongoing treatment were instituted immediately to help those involved deal with the horror of their experiences. - Since the 2001 terrorist attacks, teams of physicians, therapists, and other health professionals (many associated with universities and medical centers) have been working with survivors, families, and others affected. - Despite such efforts, many people will continue to experience long-term difficulties

Community Violence: Hazing:

- Or initiation rites, is prevalent in both high school and college. - Victims may be subjected to humiliating activities, or even illegal activities. - Hazing has reported negative consequences such as fighting; being injured; hurting other people; doing poorly in school; difficulty eating, sleeping, or concentrating; and experiencing feelings of anger, confusion, embarrassment, or guilt. - Hazing activities are most often associated with athletic teams, fraternities or other groups offering special status, prestige, recognition/admiration, and/or a sense of belonging. - The anticipation of these benefits helps lure students to participate, as well as the negative consequences that refusal may bring. - Alcohol consumption, humiliation, isolation, sleep deprivation, and sex acts are hazing practices common across students' groups, not limited to fraternities/sororities or athletics

Child Abuse:

- Or maltreatment generally is defined as the intentional injury of a child. - It can include physical abuse or injuries, neglect or failure to prevent harm, failure to provide adequate physical or emotional care or supervision, abandonment, sexual assault or intrusion, and overt torture or maiming. - In the United States, each state defines child maltreatment, identifies specific reporting procedures, and establishes service delivery systems. - Although similarities exist among the laws of all states, there is also a great deal of variation. - For this reason, accurate data on the type, frequency, and severity of child maltreatment across the country are difficult to obtain. - During 2014 in the United States, 702,000 victims were identified from over 6.6 million reports. - Of these cases, 75% were neglect, 17% physical abuse, 8% sexual abuse, and 6% emotional/psychological maltreatment. - An estimated 1,580 children died as a result of maltreatment with 70% under the age of 3 - Fathers, stepfathers, uncles, older siblings, and live-in partners of the child's mother often perpetrate abuse on girls. - About 75% of reported cases involve father-daughter incest; mother-son incest is much less frequent. - Estimates are that 15 million women in the United States were sexually abused as children, and one-third of all sexually abused victims were molested when they were younger than 9. - Accurate statistics on sexual abuse are difficult to obtain because many incidences are unreported as a result of shame and embarrassment. - In other cases, women do not acknowledge sexual abuse until they are adults. - Adults with a history of childhood sexual abuse are at a higher risk for depression, suicide attempts, marital problems, marriage to an alcoholic, smoking, alcohol abuse, chronic pain, and medically unexplained symptoms

Child Abuse: Clinical Picture:

- Parents who abuse their children often have minimal parenting knowledge and skills. - They may not understand or know what their children need, or they may be angry or frustrated because they are emotionally or financially unequipped to meet those needs. - Although lack of education and poverty contribute to child abuse and neglect, they by no means explain the entire phenomenon. - Many incidences of abuse and violence occur in families who seem to have everything; the parents are well educated, with successful careers, and the family is financially stable. - Parents who abuse their children often are emotionally immature, needy, and incapable of meeting their own needs much less those of a child. - As in spousal abuse, the abuser frequently views his or her children as property belonging to the abusing parent. - The abuser does not consider the children people with rights and feelings. - In some instances, the parent feels the need to have children to replace his or her own faulty and disappointing childhood; the parent wants to feel the love between child and parent that he or she missed as a child. - But the reality of the tremendous emotional, physical, and financial demands that come with raising children usually shatters these unrealistic expectations. - When the parent's unrealistic expectations are not met, he or she often reverts to using the same methods his or her parents used. - This tendency for adults to raise their children in the same way they were raised perpetuates the cycle of family violence. - Adults who were victims of abuse as children frequently abuse their own children

Intergenerational Transmission Process:

- Patterns of violence are perpetuated from one generation to next through role modeling and social learning - Ex: son seeing father beating his mom when growing up, so through learned role modeling he does the same to his wife when he gets married later in life)

Cycle Of Violence: Phase 3:

- Period of remorse/contrition: expressing regret, apologize, promise it will never happen again, engage in romantic behavior - Also called "honeymoon" period

Types Of Child Abuse: Physical:

- Physical abuse of children often results from unreasonably severe corporal punishment or unjustifiable punishment such as hitting an infant for crying or soiling his or her diapers. - Intentional, deliberate assaults on children include burning, biting, cutting, poking, twisting limbs, or scalding with hot water. - The victim often has evidence of old injuries (e.g., scars, untreated fractures, or multiple bruises of various ages) that the history given by parents or caregivers does not explain adequately.

Rape & Sexual Assault:

- Rape is the perpetration of an act of sexual intercourse with a person against his or her will and without her consent, whether that will is overcome by force, fear of force, drugs, or intoxicants. - Rape is a crime of violence and humiliation of the victim expressed through sexual means. - It is also considered rape if the victim is incapable of exercising rational judgment because of mental deficiency or because he or she is younger than the age of consent (which varies among states from 14 to 18 years) - The crime of rape requires only slight penetration of the outer vulva or rectum; full erection and ejaculation are not necessary. - Forced acts of oral sex and anal penetration, although they frequently accompany rape, are legally considered sodomy, which is still sexual assault. - The person who is raped may also be physically beaten and injured. - Rape can occur between strangers, acquaintances, married persons, and persons of the same sex, though seven states define domestic violence in a way that excludes same-sex victims. - Only 28% of rapes are committed by strangers, 7% for child victims -. A phenomenon called date rape (acquaintance rape) may occur on a first date, on a ride home from a party, or when the two people have known each other for some time. - It is more prevalent around or on college campuses. - The rate of serious injuries associated with dating violence increases with increased consumption of alcohol by either the victim or the perpetrator. - Rape is a highly underreported crime, less than one half of all rapes are estimated to be reported. - The underreporting is attributed to the victim's feelings of shame and guilt, the fear of further injury, and the belief that he or she has no recourse in the legal system. - Victims of rape can be any age; reported cases have victims ranging in age from 15 months to 82 years. - The highest incidence is in girls and women 16 to 24 years of age. Girls younger than 20 years were the victims in 80% of rapes reported - Rape most commonly occurs in the victim's neighborhood, often inside or near the home. Most rapes are premeditated. - As many as 50% of female victims do not acknowledge a sexual assault, minimizing it as a misunderstanding or a lesser event - This is particularly true if the perpetrator is known to the woman or is in a power position, such as a manager at work, a family member, or someone of distinction in the community. - Male rape is also a significantly underacknowledged and underreported crime. - It can occur between gay partners or strangers, but it is most prevalent in institutions such as prisons. - Over 80,000 male inmates are sexually assaulted each year, but the figure may be much higher; 60% of the sexual violence is perpetrated by prison or jail staff. - This type of rape is particularly violent, and the dynamics of power and control correspond to that of heterosexual rape

Ombudsmen:

- Report complaints of elder abuse in institutions

Women & Abuse Blaming:

- Some women mistakenly believe they're to blame for the abuse and rightfully fear that they may be killed if they try to leave the relationship

Survivors Of Abuse & Trust:

- Survivors may have hard time trusting others; especially authority figures

Suffering Of Survivors Of Abuse:

- Survivors of abuse can suffer from long-term emotional drama like PTSD, dissociative disorder, substance abuse, depression

Cycle Of Violence: Phase 1:

- Tension building

Community Violence:

- The National Center for Education Statistics publishes annual reports about school crime and safety with the most recent data coming from the 2017 report. - Death by homicide at school is less than 3%. - But in recent years, multiple homicides by a single shooter are more common than one-on-one homicide at school. - Multiple shootings make the news around the world. - Students are trained on what to do if an active shooter comes to school, and schools have increased security in a number of ways to address safety concerns (U.S. Department of Education, National Center for Education Statistics, 2017). - In an effort to combat violence at school, the CDC has been working with schools to develop curricula that emphasize problem-solving skills, anger management, and social skills development. - In addition, parenting programs that promote strong bonding between parents and children and conflict management in the home, as well as mentoring programs for young people, show promise in dealing with school-related violence. - A few people responsible for such violence have been diagnosed with a psychiatric disorder, often conduct disorder. - Often, however, this violence seems to occur when alienation, disregard for others, and little regard for self predominates.

Intimate Partner Violence: Cycle Of Abuse & Violence:

- The cycle of violence or abuse is another reason often cited for why women have difficulty leaving abusive relationships. - A typical pattern exists; usually, the initial episode of battering or violence is followed by a period of the abuser expressing regret, apologizing, and promising it will never happen again. - He professes his love for his wife and may even engage in romantic behavior (e.g., buying gifts and flowers). - This period of contrition or remorse is sometimes called the honeymoon period. - The woman naturally wants to believe her husband and hopes the violence was an isolated incident. - After this honeymoon period, the tension-building phase begins; there may be arguments, stony silence, or complaints from the husband. - The tension ends in another violent episode after which the abuser once again feels regret and remorse and promises to change. - This cycle continually repeats itself. - Each time, the victim keeps hoping the violence will stop. - Initially, the honeymoon period may last weeks or even months, causing the woman to believe that the relationship has improved and her husband's behavior has changed. - Over time, however, the violent episodes are more frequent, the period of remorse disappears altogether, and the level of violence and severity of injuries worsen. - Eventually, the violence is routine—several times a week or even daily. - While the cycle of violence is the most common pattern of IPV, it does not apply to all situations. - Many survivors report only one or two elements of the cycle. - For example, there may be only periodic episodes of violent behavior with no subsequent honeymoon period or no observable period of increasing tension.

Child Abuse: Treatment & Intervention:

- The first part of treatment for child abuse or neglect is to ensure the child's safety and well-being. - This may involve removing the child from the home, which also can be traumatic. - Given the high risk of psychological problems, a thorough psychiatric evaluation also is indicated. - A relationship of trust between the therapist and the child is crucial to help the child deal with the trauma of abuse. - Depending on the severity and duration of abuse and the child's response, therapy may be indicated over a significant period. - Long-term treatment for the child usually involves professionals from several disciplines, such as psychiatry, social work, and psychology. - The very young child may communicate best through play therapy, where he or she draws or acts out situations with puppets or dolls rather than talks about what has happened or his or her feelings. - Social service agencies are involved in determining whether returning the child to the parental home is possible based on whether parents can show benefit from treatment. - Family therapy may be indicated if reuniting the family is feasible. - Parents may require psychiatric or substance abuse treatment. - If the child is unlikely to return home, short-term or long-term foster care services may be indicated.

Elderly Abuse: Clinical Picture:

- The victim may have bruises or fractures; may lack needed eyeglasses or hearing aids; may be denied food, fluids, or medications; or may be restrained in a bed or chair. - The abuser may use the victim's financial resources for his or her own pleasure, while the elder cannot afford food or medications. - Abusers may withhold medical care from an elder with acute or chronic illness. - Self-neglect involves the elder's failure to care for him or herself.

Abuse:

- The wrongful use and maltreatment of another person - Statistics show that most abuse is perpetrated by someone the victim knows. - Victims of abuse are found across the life span, and they can be spouses or partners, children, or elderly parents.

Rape & Sexual Assault: Assessment:

- To preserve possible evidence, the physical examination should occur before the victim has showered, brushed teeth, douched, changed clothes, or had anything to drink. - This may not be possible because the victim may have done some of these things before seeking care. - If there is no report of oral sex, then rinsing the mouth or drinking fluids can be permitted immediately. - To assess the patient's physical status, the nurse asks the victim to describe what happened. - If he or she cannot do so, the nurse may ask needed questions gently and with care. - Rape kits and rape protocols are available in most emergency department settings and provide the equipment and instructions needed to collect physical evidence. - The physician or a specially trained sexual assault nurse examiner is primarily responsible for this step of the examination.

Clinical Picture Of Abuse & Violence:

- Victims of abuse or violence can certainly have physical injuries needing medical attention, but they also experience psychological injuries with a broad range of responses. - Some clients are agitated and visibly upset; others are withdrawn and aloof, appearing numb or oblivious to their surroundings. - Often, domestic violence remains undisclosed for months or even years because victims fear their abusers. - Victims frequently suppress their anger and resentment and do not tell anyone. - This is particularly true in cases of childhood sexual abuse. - Survivors of abuse often suffer in silence and continue to feel guilt and shame. - Children particularly come to believe that somehow they are at fault and did something to deserve or provoke the abuse. - They are more likely to miss school, less likely to attend college, and continue to have problems through adolescence into adulthood. - As adults, they usually feel guilt or shame for not trying to stop the abuse. - Survivors feel degraded, humiliated, and dehumanized. - Their self-esteem is extremely low, and they view themselves as unlovable. - They believe they are unacceptable to others, contaminated, or ruined. - Depression, suicidal behavior, and marital and sexual difficulties are common. - Victims and survivors of abuse may have problems relating to others. - They find trusting others, especially authority figures, to be difficult. - In relationships, their emotional reactions are likely to be erratic, intense, and perceived as unpredictable. Intimate relationships may trigger extreme emotional responses such as panic, anxiety, fear, and terror. - Even when survivors of abuse desire closeness with another person, they may perceive actual closeness as intrusive and threatening. - Nurses should be particularly sensitive to the abused client's need to feel safe, secure, and in control of his or her body. - They should take care to maintain the client's personal space, assess the client's anxiety level, and ask permission before touching him or her for any reason. - Because the nurse may not always be aware of a history of abuse when initially working with a client, he or she should apply these cautions to all clients in the mental health setting.

Rape & Sexual Assault: Treatment & Intervention:

- Victims of rape fare best when they receive immediate support and can express fear and rage to family members, nurses, physicians, and law enforcement officials who believe them. - Education about rape and the needs of victims is an ongoing requirement for health care professionals, law enforcement officers, and the general public. - These signs can educate students and others about date rape and can alert people to the characteristics of people who are likely to commit dating violence. - Examples include expressing negativity about women, acting tough, engaging in heavy drinking, exhibiting jealousy, making belittling comments, expressing anger, and using intimidation. - Rape treatment centers (emergency services that coordinate psychiatric, gynecologic, and physical trauma services in one location and work with law enforcement agencies) are most helpful to the victim. - In the emergency setting, the nurse is an essential part of the team in providing emotional support to the victim. - The nurse should allow the victim to proceed at his or her own pace and not rush through any interview or examination procedures. - Giving as much control as possible back to the victim is important. - Ways to do so include allowing him or her to make decisions when possible about whom to call, what to do next, what he or she would like done, and so on. - It is the victim's decision about whether or not to file charges and testify against the perpetrator. - The victim must sign consent forms before any photographs or hair and nail samples are taken for future evidence. - Prophylactic treatment for sexually transmitted diseases is offered. - Doing so is cost-effective; many victims of rape will not return to get definitive test results for these diseases. - HIV testing is strongly encouraged at specified intervals because seroconversion to positive status does not occur immediately. - Victims are also encouraged to engage in safe-sex practices until the results of HIV testing are available. - Prophylaxis with ethinyl estradiol and norgestrel (Ovral) can be offered to prevent pregnancy. - Some women may elect to wait to initiate intervention until they have a positive pregnancy test result or miss a menstrual period. - Rape crisis centers, advocacy groups, and other local resources often provide a counselor or volunteer to be with the victim from the emergency department through longer-term follow-up. - This person provides emotional support, serves as an advocate for the victim throughout the process, and can be totally available to the victim. - This type of complete and unconditional support is often crucial to recovery. - Therapy is usually supportive in approach and focuses on restoring the victim's sense of control; relieving feelings of helplessness, dependency, and obsession with the assault that frequently follow rape; regaining trust; improving daily functioning; finding adequate social support; and dealing with feelings of guilt, shame, and anger. - Group therapy with other victims who have been raped is a particularly effective treatment. Some people attend both individual and group therapies. - It often takes 1 year or more for survivors of rape to regain previous levels of functioning. - In some cases, survivors of rape have long-term consequences, such as PTSD, which is discussed later in this chapter.

Cycle Of Violence: Phase 2:

- Violent behavior

Women In Abusive Homes:

- Women who grew up in violent homes are 50% more likely to expect/accept violence in their own relationships

Which of the following statements about rape is most accurate? A. It is a highly reported crime. B. Most rapes are premeditated. C. Rape requires ejaculation. D. Provocative dress invites rape.

B. Most rapes are premeditated. - Rationale: Most rapes are premeditated. o Rape, an underreported crime, requires only slight penetration of the vulva. Full erection or ejaculation is not necessary. Provocative dress leading to rape is a myth.

Is the following statement true or false? The honeymoon period of violence often occurs before the first episode of violence.

False - Rationale: The honeymoon period occurs after an episode of violence; this is the period in which the abuser expresses regret and then apologizes and promises it will never happen again.

Is the following statement true or false? Adults who were abused as children are more likely to abuse their own children.

True - Rationale: The tendency for adults to raise children in the same way they were raised perpetrates the cycle of family violence. Adults who were victims of abuse as children frequently abuse their own children.

Abuser:

Typically abuser has: - Strong feelings of inadequacy - Low self-esteem - Poor problem-solving - Poor social skills

4. Which type of child abuse can be most difficult to treat effectively? a.Emotional b.Neglect c.Physical d.Sexual

a.Emotional

5. Women in battering relationships often remain in those relationships as a result of faulty or incorrect beliefs. Which belief is valid? a.If she tried to leave, she would be at increased risk for violence. b.If she would do a better job of meeting his needs, the violence would stop. c.No one else would put up with her dependent clinging behavior. d.She often does things that provoke the violent episodes.

a.If she tried to leave, she would be at increased risk for violence.

1. Which is the best action for the nurse to take when assessing a child who might be abused? a.Confront the parents with the facts, and ask them what happened. b.Consult with a professional member of the health team about making a report. c.Ask the child which parent caused this injury. d.Say or do nothing; the nurse has only suspicions, not evidence.

b.Consult with a professional member of the health team about making a report.

3. Which assessment finding might indicate elder self-neglect? a.Hesitancy to talk openly with nurse b.Inability to manage personal finances c.Missing valuables that are not misplaced d.Unusual explanations for injuries

b.Inability to manage personal finances

2. Which is true about domestic violence between same-sex partners? a.Such violence is less common than that between heterosexual partners. b.The frequency and intensity of violence are greater than between heterosexual partners. c.Rates of violence are about the same as between heterosexual partners. d.None of the above.

c.Rates of violence are about the same as between heterosexual partners.

Possible Indicators Of Elderly Abuse: Psychosocial:

•Change in elder's general mood or usual behavior •Isolated from previous friends or family •Sudden lack of contact from other people outside the elder's home •Helplessness •Hesitance to talk openly •Anger or agitation •Withdrawal or depression

Questions To Ask About Safety:

•Do you feel safe in your relationships? •Are you concerned for your safety? •Are family or friends concerned for your safety? •Are your children (if any) safe? •Do you ever feel threatened? •If you felt threatened or unsafe, is there someone you can call? Night or day? •Do you have a safe place to go if you need to? •Do you have a plan if suddenly your situation becomes unsafe?

Warning Signs Of Relationship Violence:

•Emotionally abuses you (insults, makes belittling comments, or acts sulky or angry when you initiate an idea or activity) •Tells you with whom you may be friends or how you should dress, or tries to control other elements of your life •Talks negatively about women in general •Gets jealous for no reason •Drinks heavily, uses drugs, or tries to get you drunk •Acts in an intimidating way by invading your personal space such as standing too close or touching you when you don't want that •Cannot handle sexual or emotional frustration without becoming angry •Does not view you as an equal: sees self as smarter or socially superior •Guards masculinity by acting tough •Is angry or threatening to the point that you have changed your life or yourself so you won't anger him •Goes through extreme highs and lows: is kind one minute, cruel the next •Berates you for not getting drunk or high, or not wanting to have sex •Is physically aggressive, grabbing and holding you, or pushing and shoving

Possible Indicators Of Elderly Abuse: Physical Abuse:

•Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations •Reluctance to seek medical treatment for injuries or denial of their existence •Disorientation or grogginess indicating misuse of medications •Fear or edginess in the presence of family member or caregiver

Possible Indicators Of Elderly Abuse: Indicators Of Self-Neglect:

•Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills •Inability to manage activities of daily living, such as personal care, shopping, or housework •Wandering, refusing needed medical attention, isolation, and substance use •Failure to keep needed medical appointments •Confusion, memory loss, and unresponsiveness •Lack of toilet facilities, or living quarters infested with animals or vermin

Possible Indicators Of Elderly Abuse: Neglect Indicators:

•Poor personal hygiene •Lack of needed medications or therapies •Dirt, fecal or urine smell, or other health hazards in the elder's living environment •Rashes, sores, or lice on the elder •The elder has an untreated medical condition or is malnourished or dehydrated not related to a known illness •Inadequate material items, such as clothing, blankets, furniture, and television

Common Myths About Rape:

•Rape is about having sex. •When a woman submits to rape, she really wants it to happen. •Women who dress provocatively are asking for rape. •Some women like rough sex but later call it rape. •Once a man is aroused by a woman, he cannot stop his actions. •Walking alone at night is an invitation for rape. •Rape cannot happen between persons who are married. •Rape is exciting for some women. •Rape occurs only between heterosexual couples. •If a woman has an orgasm, it can't be rape. •Rape usually happens between strangers. •Rape is a crime of passion. •Rape happens spontaneously.

Warning Signs of Abused/Neglected Children:

•Serious injuries such as fractures, burns, or lacerations with no reported history of trauma •Delay in seeking treatment for a significant injury •Child or parent giving a history inconsistent with severity of injury, such as a baby with contrecoup injuries to the brain (shaken baby syndrome) that the parents claim happened when the infant rolled off the sofa •Inconsistencies or changes in the child's history during the evaluation by either the child or the adult •Unusual injuries for the child's age and level of development, such as a fractured femur in a 2-month-old or a dislocated shoulder in a 2-year-old •High incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising of rectum or vagina •Evidence of old injuries not reported, such as scars, fractures not treated, and multiple bruises that parent/caregiver cannot explain adequately

Characteristics Of Violent Families:

•Social isolation •Abuse of power and control •Alcohol and other drug abuse •Intergenerational transmission process

Possible Indicators Of Elderly Abuse: Warning Indicators From Caregiver:

•The elder is not given an opportunity to speak for self, have visitors, or see anyone without the presence of the caregiver •Attitudes of indifference or anger toward the elder •Blaming the elder for his or her illness or limitations •Defensiveness •Conflicting accounts of elder's abilities, problems, and so forth •Previous history of abuse or problems with alcohol or drugs

Points To Consider When Working W/ Abused Or Traumatized Patients:

•These clients have many strengths they may not realize. The nurse can help them move from being victims to being survivors. •Nurses should ask all women about abuse. Some will be offended and angry, but it is more important not to miss the opportunity of helping the woman who replies, "Yes. Can you help me?" •The nurse should help the client focus on the present rather than dwell on horrific things in the past. •Usually, a nurse works best with either the survivors of abuse or the abusers themselves. Most find it too difficult emotionally to work with both groups.

Possible Indicators Of Elderly Abuse: Material Abuse:

•Unpaid bills •Standard of living below the elder's means •Sudden sale or disposal of the elder's property/possessions •Unusual or inappropriate activity in bank accounts •Signatures on checks that differ from the elder's •Recent changes in will or power of attorney when the elder is not capable of making those decisions •Missing valuable belongings that are not just misplaced •Lack of television, clothes, or personal items that are easily affordable •Unusual concern by the caregiver over the expense of the elder's treatment when it is not the caregiver's money being spent