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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