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Abuse and Neglect . Constance H. Fournier Clinical Professor Texas A & M University. Goals & Objectives. The Learner Will (TLW) be able to differentiate between the different types of abuse and neglect. TLW be able to identify risk factors associated with abuse

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abuse and neglect

Abuse and Neglect

Constance H. Fournier

Clinical Professor

Texas A & M University

goals objectives
Goals & Objectives
  • The Learner Will (TLW) be able to differentiate between the different types of abuse and neglect.
  • TLW be able to identify risk factors associated with abuse
  • TLW be able to identify protective factors associated with abuse
overview of abuse
Overview of Abuse
  • 3.3 million cases reported in 2009 (similar to previous years)
    • 60% investigated
    • Half investigated substantiated
    • About 12.5 per 1000 children
    • 1460 children died of abuse/neglect in 2005
      • 77% were children under age 4
    • 1770 children died of abuse/neglect in 2009
      • 81% under the age of 4
      • http://www.medicinenet.com/child_abuse/article.htm
      • http://www.acf.hhs.gov/programs/cb/pubs/cm09/cm09.pdf#page=58
overview of abuse1
Overview of abuse

For unique victims (abuse reported; counted once even if reported multiple times)

  • 78% suffered neglect
  • 18% physical abuse
  • 9% sexual abuse
  • 8% psychological maltreatment
  • For those who died
    • About 1/3 died from neglect alone
    • About 1/3 died from multiple abuses
school nurses initial reflection
School Nurses: Initial Reflection
  • What is your school’s policy for reporting abuse?
  • What is your role as school nurse?
  • Share with someone not in your district.
overview of sexual abuse
Overview of sexual abuse
  • Sexual abuse not thought to exist until 1970’s; or thought to be very rare
  • Greater reporting, but still thought to be underreported
  • Occurs across rural, urban, suburban settings
  • Occurs across SES groups
  • Occurs across racial and ethnic groups
overview sexual abuse
Overview: Sexual Abuse
  • Most abuse occurs with someone the child knows
    • Girls more likely inside the family
    • Boys more likely outside the family, but still in circle of trust
  • 96% of those under age 12 knew attacker
    • 20% fathers
    • 16% relatives
    • 50% acquaintances or friends
overview sexual abuse1
Overview: Sexual Abuse
  • Those 12 to 18
    • 12% Family member
    • 33% stranger
    • 55% acquaintance
  • Most abuse is within a relationship of 4 years
    • Often months spent getting the child “ready”
  • Abuse also occurs in successive generations of some families
  • Abuse occurs in 2/3 abduction cases
overview sexual abuse2
Overview: Sexual Abuse
  • About 50% of abusers are adolescent
  • About 82% of abusers are a heterosexual partner of close family member
  • About 96% to 100% of those accused are heterosexual
  • About 50% of fathers and stepfathers who abuse also abuse children outside of the family*
      • National Research Council
risk factors
Risk Factors
  • Having few friends
  • Absent or unavailable parents
  • Step family
  • Conflict with or between parents
  • Physical or intellectual disability
risk factors1
Risk Factors
  • Living separated from parents
  • Parent who was physically or sexually abused
  • Homes that are not safe (transient, drugs, prostitution)
  • Deployed parents* 40% higher than when parent home
  • *http://www.medicalnewstoday.com/articles/78421.php
risk factors2
Risk Factors
  • With those reporting sexual abuse
    • 6% no risk factors
    • 9% one risk factor
    • 26% two risk factors
    • 68% three risk factors (one study 78%)
  • Gay, lesbian, and bisexual youth are especially vulnerable because they tend to be more socially isolated (one study estimates 6 to 7 times greater chance of abuse compared with the general population)
negative effects psychological
Negative effects: psychological
  • Often have long term psychological or social negative effects
  • more than half have are fortunate not to have extreme trauma
  • Higher risk for mental health issues
  • Powerlessness interferes with coping
negative effects physical
Negative effects: Physical
  • Risk of HIV infection
  • Risk of STIs
  • Pregnancy
  • Physical impact on organs
factors worsening severity of outcome of sexual abuse
Factors worsening severity of outcome of sexual abuse
  • Younger age
  • Less developmental maturity
  • Duration of abuse (longer is worse)
  • Type of abuse
  • Abuse by parent
  • Abuse by older person
  • Lack of support upon disclosure
  • Absence of caring parent
overview of physical abuse neglect
Overview of Physical abuse/neglect
  • Tendency to lump these together, or “maltreatment”
  • 2009 of 3.3 million cases reported by states
    • about 15% was physical abuse
    • about 78% was neglect
    • About 3 million children received preventative services
    • About 60% of children who were abused received services post-abuse; 26% of nonvictims
    • About 21% placed in foster care
    • Court representation assigned to 16% of victims
physical consequences physical abuse
Physical Consequences: Physical Abuse
  • Minor
    • Bruises
    • Cuts
    • Burns
  • Major
    • Broken bones
    • Ruptures
    • Hemorrhage
    • death
physical abuse neglect
Physical abuse/Neglect
  • Shaken baby
    • Bleeding in eyes, brain
    • Spinal cord and neck injuries
    • Rib and bone fractures
  • Abuse and neglect in young children
    • Impaired brain development
    • On-going poor physical health
    • Poor nutrition and related problems
    • Dirty; inappropriate clothing
physical neglect psychological
Physical/neglect: Psychological
  • Infancy-depression and withdrawn; lack of trust; fear
  • Poorer mental health overall
    • 80% met criteria for psychiatric disorder by age 21
    • Depression, anxiety, suicide attempts seen in high numbers
  • Lower cognitive functioning; poorer academic performance
  • Social issues: antisocial traits
physical neglect behavioral
Physical/neglect: Behavioral
  • Adolescence: more problems with delinquency; pregnancy; low academic functioning; risk taking
  • Increased juvenile delinquency (11 times more likely than general population)
  • Adult crime 2.7 times more likely; 3.1 times for violent crime
  • Increased drug and alcohol abuse; as many as 2/3 of those in drug treatment were abused as children
  • Can increase abusive behavior with own children
factitious disorder by proxy
Factitious Disorder by Proxy
  • Factitious disorder in general- faking” symptoms for gain
    • Get something: attention, special services
    • Not Malingering—faking for money or other goods; or to get out of personal responsibility like work or jail
factitious disorder by proxy1
Factitious Disorder by Proxy
  • Factitious disorder with mostly psychological symptoms
    • Confusion
    • Auditory hallucinations
    • Bizarre behavior
    • Was called GanserSymdrome (prison psychosis)
factitious disorder by proxy2
Factitious Disorder by Proxy
  • Factitious disorder with physical symptoms
    • Vague pain, fever, unusual constellation of symptoms
    • Can be induced (e.g., injecting self with substances)
    • Also called Munchausen after the Baron who “embellished” stories of his life
  • Can be combined physical and psychological symptoms
factitious disorder by proxy3
Factitious Disorder by Proxy
  • In children, the symptoms are induced or concluded by the parent (typically mothers) to meet the psychological needs of the mother
  • Parent appears to be
    • very concerned
    • eager to talk with medical professionals
    • often very knowledgeable about procedures
    • seems very compliant with protocols
factitious disorder by proxy4
Factitious Disorder by Proxy
  • Warning signs
    • Dramatic but inconsistent medical history
    • Unclear symptoms that get worse
    • Relapse following improvement
    • Extensive knowledge
      • Hospitals
      • Procedures
      • “Text book” Symptoms
factitious disorder by proxy5
Factitious Disorder by Proxy
  • Many surgical scars
  • New or additional symptoms after negative test results
  • No symptoms when child is alone or not being observed
  • Parent willingness to subject child to multiple medical tests or procedures
  • History with seeking treatment with many providers or at many hospitals
  • Reluctance to allow child to talk with personal alone
factitious disorder by proxy6
Factitious Disorder by Proxy
  • How diagnosed?
    • Do symptoms make sense?
    • Is there collateral confirmation (school nurse?)
    • Parent willing to subject child to multiple tests
    • Treatments not working in predictable way
factitious disorder by proxy7
Factitious Disorder by Proxy
  • Role of child-may be stages of collusion
    • Unaware
    • Passively colluding
    • Actively colluding
    • Self production of symptomology
  • Outcomes
    • Medical issues
    • PTSD
    • Other (lack of bonding)
factitious disorder by proxy8
Factitious Disorder by Proxy
  • Treatment
    • Diagnosis – typically a team approach
      • Examining all records
      • Recording parent
      • Information from other sources
    • Child Protective Services
      • Child taken away from perpetrator
      • In some states, perpetrator jailed
    • Treatment
      • Individual therapy for child; parent
      • Family therapy
school nurse reflection 2
School Nurse: Reflection #2
  • What changes need to be made in school policies for reporting abuse?
  • What changes need to be made for the role of the school nurse?
  • How can these changes be made?
  • Be prepared to share changes with each other, and the group.
protective factors for abuse
Protective factors for Abuse
  • Nurturing and attachment
    • Health in general is better (more stress seen with families with children who are sick)
    • Trust in caregivers
    • Development is appropriate (more stress seen with families with children who are developmentally delayed)
  • Knowledge of child development
    • Realistic expectations for age of child
    • Fosters adjustment, success, motivation
protective factors
Protective Factors
  • Parental resilience
    • Models of coping that are positive and helpful
      • Utilizes resources effectively
    • More effective in day-to-day activities
      • Utilizes resources effectively
      • Good problem solving
    • More effective in dealing with stress
      • Can control self
      • Other family members can control selves
protective factors school
Protective Factors: School
  • Success at school
  • Positive relationships with one or more teachers
  • Positive relationships with peers
  • Strong bond with positive others (School nurse?)
  • Nurturing and supportive school climate
  • Conditions that foster feelings of competence, self-determination, and connectedness
      • http://smhp.psych.ucla.edu/pdfdocs/Sampler/Resiliency/resilien.pdf
  • www.childwelfare.gov
  • http://www.advocatesforyouth.org/
  • http://my.clevelandclinic.org/disorders/Factitious_Disorders/hic_Munchausen_Syndrome.aspx
  • http://my.clevelandclinic.org/disorders/Factitious_Disorders/hic_An_Overview_of_Factitious_Disorders.aspx