Families – social issues and abuse

1. Families – social issues and abuse Prof. Rosanda Mulić, MD, PhD

2. Family Issues: Marital conflict, Divorce, Abuse, Neglect • To competently serve families, medical students must understand the theories and issues surrounding family violence, adult victims of family violence, adult survivors of child abuse, child witnesses of domestic violence, adolescent victims of dating violence, elderly victims, and perpetrators of abuse.

3. Family Systems model • Primary assumptions:- Reciprocal: Individuals shape their environment and are shaped by the environment as well • Dynamic: constant interactions among individuals and their environments • Hierarchical structure: defined by boundaries and subsystems

4. Marital Conflict:Types and Child Outcomes • Physical (Domestic Violence) - Most linked with externalizing problems in children - Traumatic symptoms • Verbal Aggression – Both externalizing and internalizing problems • Withdrawal (Stonewalling) - Most linked with depression, anxiety and social withdrawal in children • Mutually respectful, emotionally regulated conflict resolution – Well adjusted children with social, problem-solving skills

5. Other Outcomes • Childhood: - Lower academic achievement - Poorer self-concept - Poorer social competence • Adulthood: • Lower SES (socio-economic status) • Poorer self-concept • Increased marital problems • Greater likelihood of divorce

6. Direct Repeated exposure to conflict undermines children’s capacity for regulating their emotional and behavioral functioning Indirect Spillover hypothesis: Impact of parenting leading to changes in emotional availability (rejection, hostility) and control (lax monitoring, inconsistent or harsh discipline) Direct and Indirect Effects

7. Divorce • Children’s post-divorce adjustment affected by magnitude and force by divorce stressors • Interpersonal and intrapersonal resources • Interaction between divorce stressors and resources

8. Divorce Models • Crisis: Acute stress with transition • Gradual adjustment • Protective factors/Stress buffers - Adults: education, employment, social support - Children: active coping skills, social support, access to therapeutic intervention - Parent-child: Maternal acceptance Consistency of Discipline

9. Divorce Models • Chronic Strain • Persistent long-term problems • Risk factors: - disruptions in parent-child relations • (inept/neglectful parenting) - Continuing discord among spouses • Loss of emotional support • Economic hardship • Negative life events (moving, changing schools)

10. Coping with Divorce • Component of effective treatmens: • Improve mother-child relationship quality: • Praise • Reflective listening • Positive activity scheduling • Improve effective discipline: • Structure and consistent • Logical consequences • Decrease pysical punishment • Co-parenting: increase father’s access to child • Reduce interparental conflict

11. Co-parenting • People who separate but continue to work cooperatively as parents: • Respectful (no criticism) • Resolve conflicts privately • Discuss major issues together an arrive at mutual understanding before speaking with children • Don’t make child “confidant” • Don’t make child “messenger”

12. Co-parenting • Points to consider: - Be clear that divorce is final and NOT child’s fault • Remember to problem solve: • Education • Visitation schedule • Finances • Medical needs • Discipline Holidays/special events • NOT RECOMENDED FOR ALL FAMILIES

13. Coping with Divorce • Componets of Effective Treatments • Coping skills training: • Emotion labelling and expression • Positive cognitive reframing to reduce negative thougts about divorce stressors • Effective communication “I” messages • Identify ways to find social support

14. Child Abuse and Neglect

15. Child Abuse and Neglect • Sexual Abuse: • Any penetration no matter how slight by penis or any object • Any sexual contact of any genital area by person’s genitals, mouth, tongue, hand etc… • Intentional masturbation • Sexual exploitation (engaging in sexual acts or prostitution).

16. Sexual Abuse Drawing of a sexually abused girl aged five

17. Provided courtesy of the staff the Children's Hospital, Klajic street Zagreb See the extension of the anus and intertrigo caused by neglect Sexual Abuse

18. Mental Injury/Emotional abuse • Injury in intellectual or psychological capacity as evidenced by a discernable and substantial impairment in person’s ability to function within the normal range of performance • Physical Harm - Acts including punching, beating, kicking, biting, burning and shaking

19. Physical Harm • Provided courtesy of the staff the Children's Hospital, Klajic street Zagreb

20. Physical Harm

21. Physical Harm

22. Correlates of Child Abuse • Parents have little exposure to positive parental models and support • Greater degree of stress in family environment • Information processing disturbances may cause parents to misperceive child’s behavior or intent • Lack of awareness or developmentally appropriate expectations • Conflict and marital violence

23. Sequelae of Child Abuse • Emotional: • Anxiety and depression • Low self esteem • Increased anger/conflict • Guilt and shame

24. Sequelae of Child Abuse • Social: • Withdrawn • Inappropriate sexual behavior • Vulnerability for re-victimization

25. Sequelae of Child Abuse • Behavioral • Runaway behavior • Selfdestructive behavior • Substance abuse

26. Sequelae of Child Abuse • Physical: • Medical problems • Somatic complains • Injuries

27. Mediating Factors of Child Abuse • Age of child:Younger children are more vulnerable and have not developed good coping skills, however, older children are more aware of social stigma with abuse • Psychological condition of victim: Child with prior emotional problems or an unstable home environment may experience more pronounced problems • Not being believed or supported especialy from others they trust

28. Mediating Factors of Child Abuse • Stranger vs. known person: • more damaging effects if assaulted by a trusted person • Sexual knowledge or experience: • child with no prior sexual experience may be more vulnerable • Type of assault: • amount of bodily harm or penetration; does child believe body has been damaged? • Repetaed assaults: • more harm of repeatedly being abused

29. Mediating Factors of Child Abuse • Therapy: • More likely to recover if they have individual therapy, and when they are ready, support group

30. Child Neglect • Physical: Inadeqaute attention to clothing, food, and health-care needs; • Emotional: Inadeqaute attention to child’s emotional and developmental needs • Educational: failure to enroll a child in school in violation of state law, permitting chronic truancy, or refusing to allow needed attention to a diagnosed educational problem

31. Correlates of Child Neglect • Poverty (most significant) • Unemployment • Housing instability • Single parenthood • High risk neighborhoods • Household crowding

32. Correlates of Child Neglect • Family interaction style and stability: • Lack of affect/apathetic; • Impulsive parents with poor planing and organization; • Lack of knowledge about childrearing; • Social isolation; • Conflict; • Infrequent and critical parent-child interaction • Children with medical or developmental problems

33. Emotional: insecure attachment, Low self esteem; Increased anger/conflict Social: Passive Withdrawn Aggressive with peers Cognitive: Impaired development due to lack of stimulation; Poor academic success Physical: Medical problems Malnutrition Sequelae of Child Neglect

34. Resilience and Adaptation • Positive relationship with at least one important and consistent person who provides support and protection; • Positive self-esteem and sense of self

35. Prevention and treatment • Early prevention is key! • However, difficult if parents cannot acknowledge maltreatment; • Parent and family focused interventions: • Training in child rearing • Stress management • Address anger patterns/disorder beliefs • Address parental expectations • Household management skills

36. Prevention and treatment • Interventions for children: • Adress children’s need for safety • Emphasize emotional expression • Adress cognitive distortions regarding “World as a scary place”

37. Other Family Issues • Siblings • Stepfamilies • Single parent families • Maternal employment • Gay/lesbian parents • Adoption?