Ch. 55
oral washing
Help patient rinse mouth with 5 ml sterile water, which is then collected in test tube, analyzed for blood group antigens, or sperm or DNA of attacker.
Pregnancy test
Obtain blood for analysis; complete vaginal examination before woman voids.
health promotion and risk management
Prevention must be the goal of healthcare providers to reduce the incidence of child maltreatment Because many adults who maltreat children were maltreated themselves, stopping the cycle of abuse will help prevent maltreatment in generations to come.
documenting
Quote the victim's exact words whenever possible. Describe the victim's physical appearance in unbiased detail, including the presence and location of injuries, such as bruises, lacerations, teeth marks, or abrasions, and the condition of clothing. Be certain to ask whether the victim bathed or washed before coming for care because this can obscure evidence and obliterate the presence of sperm or DNA material. Ask whether the woman was menstruating or using a tampon as the force of penis penetration with rape can cause a tampon to tear through the posterior vaginal wall into the abdominal cavity, causing an extreme loss of blood internally.
assessment
Take a detailed pregnancy history of children at routine health assessments because in many instances, a breakdown in the development of parenting began in the prenatal period because of such factors as a pregnancy that was unintended or not accepted, a partner who left during the pregnancy, an economic catastrophe such as loss of a job, or a long-distance move that left support people behind.
when does IPV commonly occur
The rate of intimate partner violence is so high during pregnancy that homicide from intimate partner violence is the number one cause of death in pregnant women, a finding that probably occurs because stress (from pregnancy) can be a trigger to violence.
tranquil, loving phase phase 3
characterized by kind and contrite behavior, follows the violence, lulling the victim into forgiveness and a wish to continue the relationship
Nurses can help the nation achieve these goals by
educating parents about how to parent more effectively and by identifying children or adults in school or healthcare agency settings who have been maltreated, neglected, or victim of violence.
assessment
nurses are the first individuals to identify symptoms of possible child maltreatment or IPV
Both rape and sexual assault represent deviant behavior. They lack
privacy and mutual consent, which are the elements of "normal" or usual sexual behavior, and include violence, causing them to be degrading and dehumanizing and leaving the victim feeling helpless and victimized. Review with teenagers of both sexes ways to prevent rape at routine health visits
rape
sexual activity such as intercourse or penetration of a body orifice by a penis or other object under actual or threatened force.
canceling appointment
(or simply not keep appointments) because she has an obvious black eye or a bleeding facial laceration she does not want to reveal. She may dress inappropriately for warm weather, wearing long-sleeved, tight-necked blouses to cover up bruises on her neck or arms. When undressed for a physical examination, there may be bruises or lacerations on her breasts, abdomen, or back she cannot explain. Her neck may reveal linear bruises from strangulation. Give thoughtful consideration as to whether the explanation the woman gives for a bruise or laceration correlates with the extent and placement of the injury.
nutrition
(she must cook what her partner wants or she will be beaten). She may grow anxious if her appointment is running late (she must be home to cook dinner or risk a beating).
health practices or illnesses can be confused with child maltreatment
-coin rolling -bumps from learning to walk -bone conditions lead to broken bones
ASSESSING A CHILD FOR SIGNS OF MALTREATMENT
-head trauma -missing patches of hair -cigarette burns -burns on the dorsal surface of hand -bruising (hidden or extensive) -nail biting, other mannerisms of stress -multiple fractures in different stages of healing -scalded feet and legs from being lowered into hot water
red flags
-spiral bone fractures -skull fractures -fractures in non mobile infants -injuries that dont match childs developmental level or ability -injuries that dont match the explanation of how the injury occured
findings
Acid phosphate, a component of prostatic fluid, is a substance that is not normally present in vaginal or rectal secretions but is present in semen. Determining the presence of acid phosphate can be extremely important, therefore, if the attacker is infertile or sterile, making DNA analysis difficult. Its presence may be the best evidence that rape occurred.
The most commonly accepted theory regarding why child maltreatment occurs is that a special triad of circumstances develops
A parent has the potential to maltreat a child (special parent). A child is viewed as "different" in some way by the parent (special child). An event or circumstance brings about the maltreatment (special circumstance).
signs of IVP
A woman may come for care late in pregnancy or not at all, for example, because her partner controls her transportation or money; she may have been pretending the pregnancy did not exist to reduce stress in her home. She may be noticeable in a prenatal setting because she has purchased no maternity clothing (she has no funds for herself and asking for money may incite violence). For the same reason, she may decline laboratory tests if they involve additional transportation or money.
abdominal truma
A woman who has experienced recent violence may be anxious to listen to the baby's heartbeat or have fundal height measured at prenatal visits because she is worried the fetus may have been hurt. If abdominal trauma is present, an ultrasound may be prescribed to further assess fetal health. If an ultrasound reveals minimal placental infarcts from blunt abdominal trauma, this can lead to poor placental perfusion, low birth weight, or pregnancy loss.
what age group has the hight rate of rape or sexual maltreatment
Adolescents
Measures to Prevent Child Maltreatment or Intimate Partner Violence
Advocate for high school or college courses on parenting and growth and development of children so young parents are familiar with typical growth and development of children. Help children learn problem-solving techniques so they are not overwhelmed by mounting problems when they become adults. Foster high self-esteem in children and women so they are not dependent on others but are assertive (to prevent them from becoming passive observers to maltreatment or violence). Help parents with responsible reproductive planning, so children are intended and desired. Help parents locate support people in their community, such as crisis centers or Parents Anonymous or religious or social contacts, so they have ready support people to help them manage stress. Role model caring behaviors with children for parents. Identify children who may be viewed as special in some way by parents, such as those who were separated from the family at birth, were premature, or are physically or cognitively challenged, because these children are at high risk to be victims of maltreatment. Identify parents who were maltreated as children and offer specific help to them to break the chain of child maltreatment. Advocate and support laws that implement the "No Hit Zone" in public places such as hospitals and school settings.
asking the parent and the child
Ask children about the injury as well as the parents because if they did not hear the parent's explanation of the injury, they may say something that is inconsistent with the parent's explanation.
asking questions
Asking all women at physical examinations to account for any bruise they have helps detect physical maltreatment. Asking them whether they are ever concerned about their safety or well-being during well visits helps detect and prevent this type of maltreatment.
car
Avoid isolated parking places; park near a building or in a lot with a parking attendant. Lock your car when waiting in it and after parking it. Look in the backseat before unlocking and entering your car to be sure no one is there. Have your car key ready when you approach your car; do not stand fumbling for it.
Because child maltreatment is a crime, the healthcare record of the child can be subpoenaed and displayed in court.
Be certain, therefore, when charting information related to child maltreatment that you make specific and factual notes (observations, not interpretations), such as "Parent spoke loudly and slurred his words," rather than "Parent was intoxicated," or "Mother stated, 'This child is nothing but trouble,'" not "I think this mother dislikes this child." Photographs of physical maltreatment enhance the strength of the testimony of maltreatment, so these are usually taken.
social settings
Be clear with your date that when you say no, you mean no. Limit alcohol use because it can lead to risk-taking behavior. Make it clear you consider date rape the same as any rape and you will press charges. Flunitrazepam (Rohypnol) is a sedative, known as a "date rape" drug. Do not date any individual who brags that he knows how to obtain it or use it.
To diagnose this disorder, covert video surveillance may be necessary
Because this syndrome reveals distorted perceptions on the part of the parent, it is almost always necessary to remove the child from the home to protect the child, even if the parent receives counseling.
Remembering the 3 Bs, a light-hearted although meaningful phase for such an important situation, may help with assessment
Bruises on Babies are nearly always Bad
Parents may also be identified as being able to maltreat children during health maintenance visits.
By the time a baby is brought to a healthcare agency for the initial health maintenance visit, you should be able to see that positive parent-child interaction has begun. Listen for parents who say the baby is "nothing but trouble," "cries all the time," or "is bad." Ask new parents how it feels to be a new parent. "I'm exhausted but enjoying it" is a different answer from "It takes too much time" or "It's not much fun."
Gonococcus smear
Culture the patient's cervix, vagina, and rectum (also throat if oral coitus was attempted).
Some indicators of emotional abuse include:
Developmental delays Bed-wetting without medical cause Frequent psychosomatic complaints Severe depression Anxiety or aggression Self-destructive behaviors such as self-harming Overly compliant child
home
Do not advertise that you stay home alone while a parent works or is on vacation. Do not allow anyone to your house when you are home alone, even meter readers or repairmen who produce identification. Insist on adequate lighting for hallways in an apartment building or streetlights around your home. Have your house key in your hand when you approach your door; do not stand fumbling for it by the doorway. Keep your doors and windows locked when you are alone at home.
work or school
Do not enter an elevator with a stranger. Lock the outside door and do not admit people you do not know when working alone in an office or classroom at night. Ask for security protection to walk out to your car after hours. When going to and from school or work after dark, walk in the street rather than next to shrubs or dark buildings.
Personal Actions
Do not wear chains around your neck that could be used to strangle you. Learn self-defense; scratch the attacker to obtain skin and blood specimens under fingernails. Be aware that an attacker could take any weapon you hold away and use it on you; use caution carrying a weapon or mace. If an attack occurs, observe the attacker's appearance as carefully as possible. Note identifying characteristics, such as a birthmark, scar, tattoo, words, or manner of speech, to be able to identify the individual later. Press charges in court to make rape a crime of extreme magnitude and as an opportunity to fight back. Work to provide rape prevention information and a united front against rape in your community.
Blood Venereal Disease Research Laboratory (VDRL), HIV, and hepatitis B surface antigen (HBsAg)
Draw blood for antibody titer for syphilis, HIV, and hepatitis B and typing to differentiate it from attacker's type.
other signs of neglect
Failing to bring a child for medical attention or failing to seek early medical care for an infection are other signs of neglect. Not requiring a child to attend school, deliberately keeping a child out of school without setting up a home school program, or allowing a child to go unsupervised after school may also be interpreted as neglect. Such actions may be willful or they may occur if parents simply do not realize the developmental needs of a child.
Two classic findings of the syndrome are usually present:
First, the symptoms are not easily detected by physical examination, only by history; and second, the symptoms are present only when the person initiating the symptoms is providing care (they disappear when care is provided by another person).
Helping parents to seek assistance from support people is another necessary step in prevention
Home visits, family counseling and therapy, and referral to organizations for parents who maltreat children, such as Parents Anonymous, can be highly effective in encouraging parents to reach out for help in times of crisis.
other signs of maltreatment
Human bites or chunks of hair pulled off the scalp are other signs of maltreatment. Head injuries and broken bones are also frequent findings. Children who are preschool age and younger usually do not fall far enough under normal circumstances to break bones; a broken bone at this age, therefore, suggests the child was thrown or struck so hard the bone broke. Other common findings include multiple fractures in different stages of healing, rib or occipital fractures, and metaphyseal-epiphyseal injuries.
A second provision in state laws is protection from having a lawsuit brought against a healthcare provider for reporting suspected maltreatment "in good faith" that is then proved false.
In other words, the laws are written to make it better to err on the side of reporting suspected maltreatment rather than not reporting it, from both a child safety standpoint and a legal perspective. When maltreatment is officially reported, parents need to be told child maltreatment is suspected because open lines of communication with parents are important to both protect the child and to arrange counseling for the parent who has maltreated the child.
diet
Infants are immediately placed on a diet appropriate for their ideal weight (the weight they would have been normally for their age). Rapid weight gain on this diet is diagnostic that their presenting illness was nonorganic failure to thrive.
Questions to Ask to Detect the Potential for Child Maltreatment in New Parents
Is the parent enjoying this new role? Does the parent establish eye contact with the baby? How does the parent talk to the baby? Is everything expressed as a demand? Are most of the parent's verbalizations about the child negative? Does the parent remain disappointed about the child's sex or appearance? Are the parent's expectations for the child's development far beyond the child's capabilities? Is the parent very bothered by the baby's crying? Does he or she ignore the baby's demands to be fed? When the baby cries, is the parent able to comfort the child? What is the parent's reaction to the task of changing diapers? Is the parent repulsed by the messiness? Can the parents name a support person they can turn to for advice or assurance? Is sibling rivalry a problem? Is the husband jealous of the baby's claim on the mother's time and affection? When a parent brings the child for health care, does the parent become involved with the baby's needs during the examination and while in the waiting room? Or does the parent relinquish control to the healthcare provider or nurse such as undressing the child, holding the child, or allowing the child to express fears? Can attention be focused on the child in the parent's presence? Can the parent see something positive in that focus? Does the parent report nonexistent symptoms in the baby? Describe the child in terms that you do not recognize at all? Call with strange stories, such as the child has stopped breathing, changed color, or is doing something "on purpose" to aggravate the parent?
On physical examination, these infants usually demonstrate typical characteristics such as:
Lethargy with poor muscle tone, a loss of subcutaneous fat, or skin breakdown Lack of resistance to the examiner's manipulation, unlike the response of the average infant Rocking on all fours excessively, as if seeking stimulation Possibly a greater reluctance to reach for toys or initiate human contact than is demonstrated by the average infant; diminished or nonexistent crying Staring hungrily at people who approach them as if they are starved for human contact Little cuddling or conforming to being held Delays in sitting, pulling to a standing position, crawling, and walking because the child spends so much time alone Markedly delayed or absent speech because of the lack of interaction
Identifying parents who may be at risk for maltreating their child is a necessary step in prevention.
Listen carefully to the way pregnant women or their partners talk about the child they are expecting. A parent who is overly concerned about the physical appearance or sex of the child ("This had better be a girl" or "He'd better not have his father's nose" or "She better have good hair") may have difficulty accepting a child who does not meet these expectations. Listen for a parent who is concerned about "not letting children get the upper hand" or who says a child "had better be good." Such parents may be conveying worry about how they will act when a child is "bad."
children who are maltreated
Maltreated children tend to be viewed by parents as somehow "different." They may be more or less intelligent than other children in the family; they may have been unplanned, or they just may not live up to their parents' expectations in some way. LGBTQ
level 2
Maltreatment is becoming more frequent; beatings are sustained and cause fractures, such as a broken jaw or rib fracture.
level 3
Maltreatment is even more frequent, perhaps daily. A weapon, such as a gun, baseball bat, or broom handle, may be used. Permanent disability or death from injuries, such as intracranial hemorrhage or concussion, may occur.
level 1
Maltreatment is occasional; consists of slapping, punching, kicking, verbal maltreatment. Contusions occur.
Determining the actual incidence of rape is difficult; it seems to be more prevalent than formerly but that may be because more people report it.
Many adolescents want to avoid the secondary, but no less severe, trauma associated with reporting rape and therefore do not report it. This leaves them, unfortunately, without the immediate treatment and follow-up care that are so important to a complete recovery.
proving privacy
Many people may want to ask the victim questions, including police officers or detectives, the victim's family, a rape trauma team, and an examining primary healthcare provider. Describing the experience is good, but lack of privacy during a perineal examination demonstrates little concern for the victim's self-esteem
Several injuries in children clearly signal probable child maltreatment
Most parents protect their children's hands carefully; in contrast, children who are maltreated have a higher incidence of hand injury. Children who are beaten with electrical cords, belts, or clotheslines have peculiar circular and linear lesions Children who are beaten with a belt buckle may have additional curved lacerations from the imprint of the buckle; few other objects produce such contusions. Abrasions or ecchymotic areas on the wrists or ankles may be present if the child was tied to a bed or against a wall.vv
legal considerations
Nurses working in emergency departments may be asked to testify in court about a rape victim's appearance after the assault, although the documentation in the record is usually all that is necessary. Many victims, especially adolescents, do not press charges against their assailants because they were too frightened or unable at the time to observe the assailant's appearance and therefore cannot identify him later.
The condition is usually divided into two categories:
One where severe loss of weight can be explained because of organic causes, such as cardiac disease, and a second that occurs because of a disturbance in the parent-child relationship, resulting in maternal role insufficiency (a nonorganic cause). Sometimes, both forms combine to play a role in failure to thrive
Nursing diagnoses associated with child maltreatment or family violence should address both the physical and the emotional results of the concern. Some examples are:
Pain related to burn on hand from documented child maltreatment Risk for injury related to previous intimate partner violence Risk for other-directed violence related to admitted poor self-control Impaired parenting related to high level of stress Compromised family coping as manifested by child maltreatment related to alcohol use by father Disturbed self-esteem related to stalking and sexual maltreatment
Vaginal washing
Place 5 ml of sterile saline into patient's vagina and aspirate again to detect sperm, DNA, and acid phosphate.
The mark of a developed nation is the ability to protect the health of its most vulnerable members. This makes both child maltreatment and intimate partner violence national health concerns. Examples of 2020 National Health Goals that specifically address these issues are:
Reduce the rate of maltreatment of children younger than 18 years of age from a baseline of 9.4 per 1,000 to a target level of 8.5 per 1,000. Reduce the rate of child maltreatment fatalities from a baseline of 2.4 per 100,000 to a target level of 2.2 per 100,000. Reduce the rate of physical, sexual, and psychological violence by current or former intimate partners. Reduce stalking by former or present intimate partners. Reduce abusive sexual conduct and rape
person at fault
Remember when taking history that maltreatment is not always done by parents, so a parent could really not know how an injury occurred. Alternate caregivers such as daycare workers, a babysitter, or a nonbiologic parental figure (the new spouse) could be the person at fault.
When taking history, always ask caregivers to account for any injury to a child's body.
Remember, however, that most childhood injuries are the result of unintentional injuries caused by the child's inability to distinguish safe situations from dangerous ones or by parents' overestimating their child's ability to do such things as lighting a fire to burn trash or using a saw for a wood project.
Hair samples
Remove both scalp and pubic hairs of patient (about 10) to be compared with attacker's.
ritual maltreatment
Ritual maltreatment is cult-based or religiously, spiritually, or satanically motivated and typically involves physical, sexual, or psychological maltreatment with bizarre or ceremonial activities. With this type of maltreatment, multiple perpetrators may maltreat multiple victims over an extended period
Clothing
Save any clothing stained or torn as evidence of violent attack.
Fingernail scraping
Scrape under all of patient's fingernails so scrapings can be analyzed for blood, skin, DNA, and clothing fibers of attacker.
Vaginal smear for sperm and DNA
Swab vagina with a dry applicator and smear onto slide so sperm and DNA analysis can be performed.
acute violence stage 2
The acute violence phase can be triggered by a response from the intimate partner or by an external crisis and can result in extreme physical harm to the victim
Allowing young children to play with anatomically correct dolls is a common method for determining whether sexual maltreatment is occurring
The average reaction of a preschooler or young school-age child who has not been maltreated, for example, is to undress the dolls, giggle for a moment or two about how they look, and then redress or put them aside. The child who is involved in an incestuous relationship may make the dolls perform a sexual act, such as placing the male doll's penis into the female doll's mouth Asking the child to draw a picture of what happened may also be an effective way of revealing sexual maltreatment. BOX 55.6
IDENTIFYING SIGNS OF SEXUAL MALTREATMENT
The child reports she has had sexual activity with an adult. The child demonstrates an awareness of sex or a sexual vocabulary beyond her age expectations. The child participates in sexual expression with dolls. A girl younger than 15 years of age is pregnant. A perineal, vaginal, or anal exam reveals inflammation or vaginal tears or anal fissures. A child younger than 15 years of age has a sexually transmitted infection. A child has a history of symptoms of increased anxiety such as a sleep disturbance, development of nervous tics, nail biting, or stuttering. There is a change in school performance, school phobia, or truancy. The child voices a fear of being left alone with a certain adult. A child reports vague abdominal pain or demonstrates acting-out behavior.
implementation
The most important intervention related to family child maltreatment or intimate partner violence is prevention. Nurses can do much in all settings to be particularly observant for families who seem to be at risk for maltreatment or violence and role model optimal ways to handle family stress. Further education is an intervention that can help parents who may not recognize their children's needs or normal child behavior to learn healthy patterns of childrearing.
Expected outcomes should focus on specific examples of improved family interaction, such as:
The parent holds baby in a caring manner and maintains good eye contact. The parent attends full series of counseling sessions on learning better parenting. The parent states she has the Crisis Center telephone number on her cell phone and will call for help if she feels under threat by her partner. The adolescent states she can still think of herself with high self-esteem despite rape by stepbrother. The parent attends monthly meetings of Parents Anonymous.
third stage
The woman is forced to become isolated; she sinks into hopelessness and depression. This phase is often referred to as psychological infantilism or learned helplessness. To stop the cycle from repeating after a period of calm, she needs healthcare personnel to recognize her circumstances and offer her help.
Without an effective relationship, when a child is injured, parents who are unable to deal with stress may not show the usual degree of compassion for their child's pain or offer comfort.
They may appear more concerned with how the injury affects them than how it affects the child, saying, "Don't cry. You'll make me look like a bad parent," rather than, "It's okay to cry. I know that hurts." They may not seek treatment for an injury in an expected amount of time
To prevent maltreatment, a child may assume a role reversal with the parent or become the comforting, solacing person.
They recognize very early in life that when a parent is upset, they will be hurt. They learn to comfort the parent and reduce the parent's stress and anxiety, thereby avoiding the hurt. For this reason, it is important to assess who is comforting whom when a childhood injury occurs.
child maltreatment
This may be physical (the child is beaten or burned), it may be neglect (the child is not fed, clothed, supervised properly, or offered medical care or educational opportunities), or it also could be psychological or emotional (a child is made to feel unintelligent or inadequate).
Skin washings
Touch any dried stains of blood or semen on the patient's skin or clothing with a moistened cotton swab to be analyzed for attacker's blood, semen, or DNA.
other tests
Vaginal and anal cultures are taken for gonorrhea, and a Pap test is also performed. Blood is drawn for a pregnancy test and a Venereal Disease Research Laboratory (VDRL) test for syphilis if appropriate. Prophylactic administration of antibiotics against gonorrhea and syphilis may be necessary. If the woman is not menstruating, she may be given "morning after" therapy to avoid pregnancy. The victim may have a baseline blood sample drawn to diagnose HIV and hepatitis B status.
management
With rare exceptions, children with failure to thrive need to be removed from the parents' care and hospitalized for evaluation and therapy. Otherwise, the syndrome may lead to permanent neurologic damage or leave a child cognitively challenged because of protein deficits and interference with brain metabolism. If an infant is admitted to a hospital, studies other than routine admission blood work and urinalysis are usually delayed to avoid submitting such an understimulated child to pain or unnecessary manipulation.
rape is
a crime of violence, not of passion, and includes "date rape," a situation in which an individual forces a date or casual friend into having coitus despite a voiced unwillingness or inability to consent
rape trauma syndrome
a form of posttraumatic stress syndrome, and they usually occur in two stages: disorganization and reorganization.
After preliminary observations,
a gynecologic or anal examination will be done to evaluate the physical condition of the victim and to document that rape occurred by the presence of any vaginal or perineal lacerations or sperm or DNA left behind by the assailant on the perineum or in the vagina or rectum.
His violence-prone characteristics usually erupt early in the courtship and grow progressively worse as he uses violence to handle even small conflicts, which instills
a pervasive feeling of powerlessness in the people around him. Such men usually have a history of early and prolonged exposure to family violence as children; alcohol is frequently associated with the expression of violence
In addition to physical signs, a suspicion of sexual maltreatment may first be revealed by
a young girl worrying she is pregnant or a child's abnormal anxiety about a parent returning home from a hospital stay or being left with or cared for by a particular individual in the family Young children who are the victims of this type of relationship typically have extremely low self-esteem and may believe they are so inadequate they deserve to be treated this way.
Although victims can be of any age and either male or female, the average rape victim is an
adolescent girl. The rapist may be a relative or family friend, and rapists frequently commit the act in the neighborhood where they live. Up to 75% of girls know their attacker
The nonorganic type is considered a form of child neglect,
although this represents a very complex interplay between parent and child. In many instances, the parent feels little emotional attachment to the child and often has a history of frequent moves and little family support. The parent may not be offering enough food because of the lack of attachment, he or she is not aware of the hunger cues the infant is offering, or the parent does not have enough concern for the child to offer food regularly.
To remain objective,
always assume the parents have done the best they could under the circumstances in which they found themselves. The fact they have brought the child for care means they are seeking help; it may be their way of saying, "Help me; I don't want this to happen again." In many instances, child maltreatment is not an isolated phenomenon or a parent is also a victim and needs as much help and protection as the child.
pedophile
an adult who seeks out prepubescent children (Tanner stage 0 to 1, usually younger than 12 years of age) for sexual gratification
cigarette burns
another common finding on the bodies of physically maltreated children. A fresh cigarette burn causes a blister that resembles the scab of impetigo; differentiation at this stage is often difficult. Impetigo lesions, however, heal without scarring. Cigarette burns heal with a definite circular scar.
permissive reporters
are encouraged to report suspected child abuse but are not required by law.
postpartum period
be aware of parents who do not touch their infant within 24 hours and those who make disparaging remarks about the child's appearance, as this lack of contact could signal risk. Remember, though, not all parents immediately bond or react warmly to their newborns. Many may only tentatively touch or pick up their infant immediately.
Sexual maltreatment
broadly defined as any sexual contact between a child and an adult Child sexual abuse is evident when the activity is intended to gratify or satisfy the needs of the other person. Such a scenario can include an adult or another child who is in a relationship of trust or power due to age. This type of relationships includes but is not limited to the coercion of a child to engage in any unlawful sexual activity or the exploitation of a child in prostitution or pornographic performances and materials
outcome identification and planning
center first on ensuring the safety of the maltreated family member and minimizing the effects of trauma. Second comes reporting the discovery to authorities as nurses are mandated by law to report child maltreatment. Long-term planning includes helping a maltreated family member find safe refuge and re-establishing self-esteem through a self-help or advocacy program.
Children younger than 4 years of age are at greater risk for child abuse then older children as are those who require an increased caregiver burden such as
children with disabilities, mental retardation, mental health issues, and chronic illness
Maltreatment, formerly termed abuse
defined as the "willful injury by one person of another" and takes many forms: physical or emotional maltreatment, neglect or sexual maltreatment, intimate partner violence, and maltreatment or violence of the elderly.
It involves the coercion of
dependent, developmentally immature children or adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate the social taboos of society.
Incest results in
destructive relationship because it causes a great deal of guilt and loss of self-esteem in both the abusing and the maltreated person. The abuser is aware that this act is not culturally approved but still is unable to end the relationship; the victim recognizes this act as wrong but is unable to resist the advances. Other members of the family are likely to suspect the maltreatment is occurring but are helpless to do anything about it; this leads to guilt and feelings of worthlessness on their part for not being able to protect the victim.
flunitrazepam (Rohypnol)
drug easily dissolved in a drink, has led to an increase in the incidence of date rape because it leaves a victim with little or no memory of the event It may be very difficult for the victim of date rape to find a sympathetic ear if her companion insists he meant no harm; he simply didn't believe her. Urge adolescents to be aware of the danger of the drug and to say "no" convincingly
physical examination
examined at a well-child visit or because of illness, be certain they are fully undressed (including removing all bandages and adhesive bandage) so their entire body can be observed. Plot height and weight on a standard growth chart. Delays in growth may suggest neglect
Maltreatment is strongly associated with
excessive parental use of drugs such as alcohol, substances that remove inhibitions and self-control.
Megan's Law
federal law that requires law enforcement authorities to report to neighbors when a sexual abuser moves into a neighborhood. Parents need to be aware of this law and insist that it should be enforced so they can take appropriate precautions to protect their children's safety
burns or scalds
frequent injuries in maltreated children. The peak age at which children unintentionally burn themselves is 2 years; the peak age of burns related to maltreatment is closer to 3 years. When children burn their hand by accident, they usually burn the palm; burns from maltreatment are often on the dorsal surface. Scalding with hot water can occur from a child pulling a hot cup of coffee or a coffee maker off a table. This can, however, be child maltreatment
Many rape victims demonstrate
immediate physical and emotional symptoms that can last for weeks.
victims can be confused and further traumatized by police officers who
imply they provoked the attack because of their manner of dress or could have done more to resist or prevent the event. This increases a victim's feelings of shame and degradation.
Psychological maltreatment
includes constant belittling or threatening, rejecting, isolating, or exploiting a child or is the absence of positive parenting.
For the victim to bring charges against the attacker
information concerning the victim's appearance and history needs to be detailed in the record. For that reason, a sexual assault nurse examiner (SANE nurse) should be called if available. Pediatric nurses trained as sexual assault examiners are called P-SANE nurses and are a crucial part of properly examining a child assault victim.
Child pornography
involves photographing or describing sexual acts by any medium involving children or distributing such material in person or by mail, fax, cell phone, or over the Internet. Child prostitution involves arranging or participating in sexual acts with children. Both of these phenomena are demeaning to children and are illegal. Child prostitution carries the additional risks of sexually transmitted infection and violence, the same as adult prostitution.
If maltreatment or violence in any form is suspected,
it is essential to get as full a picture as possible. If child maltreatment is suspected, talk with the parents first, without the child, and then interview the child separately to help uncover any inconsistencies in the parents' explanations. Remember, however, you are not investigating the concern—you are doing an initial screening to assess the need for referral and reporting. your agency's patient protective services department will do the actual investigation.
Sexual maltreatment is physically and emotionally destructive because
it leaves children unable to trust others and may result in a sense of ambivalence toward intimacy and an overall sense of worthlessness. Remind parents to teach children by preschool age that their bodies are their own and to report anyone who tries to touch them in their private parts
the average rapist is a
late adolescent man with a background of aggressive behavior. His motivation usually relates to expressions of power or anger; sexual satisfaction does not appear to be a dominant motive. An excessive amount of alcohol intake often precedes rape Rape tends to be a repetitive, planned activity on the part of the attacker rather than an isolated event.
intimate partner violence
maltreatment by a family member against another adult living in the household, such as a spouse or significant other. Spouse or partner maltreatment and child maltreatment may both exist in a family. It is vital for nurses to provide family-centered care to help identify and intervene with these situations. As many as 20% to 30% of women seen in emergency departments are there because they have been maltreated by their intimate partner. Common injuries suffered include burns, lacerations, bruises, and head injuries
State laws typically identify two levels of responsibility for reporting child maltreatment:
mandatory reporters and permissive reporters.
reorganization phase 2nd phase
may last for months or years. Many rape victims report recurring nightmares, perhaps sexual dysfunction, and continuing inability to relate to the opposite sex or to face new and surprising situations. They may continue to have a great deal of difficulty discussing the rape. Many rape victims, trying to escape, change their residence at great sacrifice to finances and lifestyle. If not offered constructive counseling, victims may still feel guilt or shame when thinking about the rape as long as 20 to 30 years later.
physical neglect
more subtle form of maltreatment than physical maltreatment, but it can be just as damaging to a child's welfare. A neglected child may appear unwashed, thin, and malnourished or be dressed inappropriately, such as without mittens, a coat, or shoes in cold weather. In some families, no one has a warm coat to wear or receives enough food because there is no money for these things; that is, different from the family in which parents do have these things, but the children or one particular child does not.
management
must be reported because this is a criminal offense. It's important, as with all child maltreatment, that information about the maltreatment is collected objectively so the adult's rights are respected and the testimony is therefore admissible in court.
impact phase (stage I),
or the light level of violence, the victim uses denial as a defense mechanism. By not stopping or facing what is happening, however, she is indirectly giving the offender permission to continue.
Maltreatment not only places a child at immediate risk for harm but can also lead to long-term effects. For example,
physically maltreated children are found to be more angry, noncompliant, and hyperactive than others; they may demonstrate poor self-control and low self-esteem. Children whose parents do not interact with them (emotional maltreatment) are apt to be more withdrawn and to have a flatter affect than others
Another nursing responsibility aimed at
preventing child maltreatment is helping young parents learn about normal growth and development of children and how to better respond to the child's behavior Courses in high school or college that describe sound parenting and review normal growth and development and the responsibilities involved in parenting are additional measures in preventing child maltreatment. Parenting classes conducted in high-risk prenatal settings might also have an impact.
Abusive head trauma,
previously known as shaken baby syndrome, is the repetitive, violent shaking of a small infant by the arms or shoulders, causing a whiplash injury to the neck, edema to the brainstem, possibly subdural hemorrhage, and distinctive hemorrhages to the retinas (Hitchcock, 2012). A controversial diagnosis, and one difficult to prove, it is a particularly insidious form of child maltreatment because the damage inflicted on the infant is not readily apparent. Increased use of computed tomography (CT) scans and magnetic resonance imaging is helping to detect children with these internal symptoms. Parents may bring a child for care because they have used a covert camcorder ("a Nanny cam") to reveal that a caregiver shook their baby this way.
Mandatory reporters
professionals who are mandated by law to report child maltreatment. Nurses are included in the mandatory category in most states; this means they must report suspected child maltreatment when they identify it. Failure to do so can result in a fine, jail time, or loss of nursing licensure. The fact that the information was given in a confidential interview does not free a nurse from this responsibility (it is an exception under the confidentiality rules of the Health Insurance Portability and Accountability Act [HIPAA])
Factitious disorder, formally known as Munchausen syndrome by proxy,
refers to a parent who repeatedly brings a child to a healthcare facility and reports symptoms of illness when, in fact, the child is well
hebephile
seeks out pubescent children (Tanner stage 1 to 4, usually age 11 to 15 years)
Incest
sexual activity between family members. It often involves an older man and a young girl, although it may involve an older woman and a younger boy, a brother and sister, or a same-sex partner. It may involve foster, adopted, and stepchildren.
Statutory rape
sexual activity with a person under the age of consent (in most states, younger than 18 years of age) and is considered to have occurred regardless of the apparent willingness of the underage person.
Children who have been sexually maltreated
sexual vocabulary beyond that expected of a child their age. On physical exam, girls will have tears or inflammation of the vagina or perineum; both sexes may have rectal tears or symptoms of a sexually transmitted disease. Nurses need to keep in mind that less than 5% of children who are sexually abused will have a physical finding upon examination. This is due to the noninvasive forms of abuse, the elasticity of the hymen and other ano-genital structures, and the rapid healing of ano-genital injuries without residual injury
Child maltreatment is associated with
stress and has been linked with the inability of a family to handle external and internal stressors. Accordingly, maltreatment or violence in a family is rarely an isolated event but rather an indication of many other factors that require intervention
The third factor in child maltreatment is
stress, which may be a response to an event that would not necessarily be stressful for an average parent. It might be something as common as a blocked toilet, an illness in the family, a lost job, a landlord asking for the rent, or a rainstorm that cancels a picnic. Child maltreatment crosses all socioeconomic levels because stress of this nature occurs at all levels. Stress generally has a greater impact on individuals who do not have strong support people around them.
parents who maltreat
substance abuse, mental health issues, young age, low education and income, single parent status, and having multiple dependent children they were maltreated as a child unfamiliar with growth and development unrealistic expectations of the child social isolation
A cycle of violence often follows three phases:
tension-building, acute violence, and a "honeymoon" or tranquil, loving phase.
An important mark of maltreatment in contrast to an unintentional injury is that
that the injury is out of proportion to the history given by the parent or caregiver
Physical maltreatment is
the action of a caregiver that causes physical injury to a child. It is commonly revealed by burns or by injuries to the head or hands
psychological counseling
the child to improve self-esteem and the adult to channel sexual expression to less destructive outlets. To improve the child's self-esteem, the adult in the relationship needs to admit the fault was the adult's, not the child's. Follow-up care is best done by one of the providers who sees the child initially, so that the child does not have to recount the incident to strangers again and again. Treatment for sexually transmitted infections or protection against pregnancy should be provided as needed.
With advanced failure to thrive,
the child's nutritional status may be so extremely poor that the infant is near acidosis from starvation. If an upper respiratory tract infection should develop, the child's resistance to infection may be so low that it could result in death from secondary infections such as pneumonia.
tension-building 1st phase
the offender displays actions such as anger, arguing, and blaming the victim for external problems or for provoking the violence.
who is commonly the offender
the offender is a family member or a trusted outsider and the relationship has been occurring for some time before it is reported, parents may feel guilty they allowed the family member to have access to the child or did not listen to a child's protestations that being alone with this family member was uncomfortable for the child.
second stage,
the victim can no longer deny the violence is occurring. At the same time, she cannot stop it because she does not provoke the violence; she is only a convenient recipient of poorly controlled extreme behavior. She is forced to use coping mechanisms such as becoming very obedient and cooperative and doing everything her partner asks in a desperate effort to reduce the violence
unintended and unwanted pregnancy
they were unable to fight off sexual advances from their abusive partner. Other women may desire the pregnancy because they believe having a child will change the partner and make him a better person or having an infant will offer her someone who loves her.
The reason why intimate partner violence occurs is perplexing, but violent family situations can be divided into two groups:
those in which violence preceded the relationship or children and those in which the violence developed after the relationship was established or children were born.
After an official report of child maltreatment has been made to a child protection agency, a hospital has the right, in most instances,
to hold the child for 72 hours for protection to give an appointed caseworker time to investigate whether maltreatment has occurred. After the 72 hours, a court proceeding will determine whether the child should be returned to the parents' care or kept in a safer location.
sexual assault
typically used to refer to other forced sexual acts, such as oral-genital or anal-genital acts
Failure to thrive
unique syndrome in which an infant falls below the 5th percentile for weight and height on a standard growth chart or is falling in percentiles on a growth chart.
Molestation
vague term that includes "indecent liberties" such as oral-genital contact, genital fondling and viewing, or masturbation.
disorganization phase 1st phase
victims feel a combination of humiliation, shame and guilt, embarrassment, anger, and vengefulness. They feel that their lives have been completely disrupted by the crisis because they were unable to protect themselves from the assault. They may tremble from fear or be in great pain from perineal lacerations and are apt to startle visibly at the sound of anyone approaching or touching them. They need gentle, sympathetic support in the days after the event to allow them to feel safe. They may have nightmares of the attack occurring again. This immediate stage of disruption and disorganization usually lasts about 3 days.
rapist
whose crime is violent, both pedophiles and hebephiles may be very gentle and limit the involvement to molestation. Such persons are usually male, but sometimes female; they may have suffered sexual maltreatment as a child and thus repeatedly select children or young adolescents who are of the same age at which the maltreatment occurred. The relationship may involve people with either homosexual or heterosexual orientations. Many pedophiles or hebephiles take photos or videos of their activities with children to use for sexual gratification at a later date.
