Interpersonal Violence and Family Dynamics: Child Abuse, Elder
Abuse, Aging Family
Interpersonal Violence
- is the intentional use of physical force or power, threatened or actual, against oneself,
another person, or a group or community that either results in or has a high likelihood
of resulting in injury, death, psychological harm, maldevelopment, or deprivation.
Types of Abuse
1. Physical abuse
2. Sexual abuse
3. Emotional abuse
4. Neglect
5. Economic abuse
Crisis Situation
- Situation that puts stress on a family with a violent member.
- Perpetrator
oAny household member who is violent toward another
- Vulnerable person
oFamily member upon whom abuse is perpetrated.
oOther terms: victim, survivor, or victim/survivor
Survivor: recognizes recovery and healing process
Child Abuse
- Acts of commission
odeliberate and intentional. They include physical, sexual, and emotional abuse.
- Act of omission
oNeglect; occurs when a child’s basic physical, emotional, or educational needs
are not met or when a child is not protected from harm.
- Epidemiology
o2.4 million referrals for child abuse & neglect in 2018
o73%: Neglect
o46%: Physical abuse
o8%: Medical neglect
o28% younger than three
o15% less than one year old
o78% of deaths: Children younger than 4
oAbout 92% of child abuse perpetrators are the victim’s parents
- Co-Morbidities
oThe occurrence of one type of abuse is a strong predictor of the occurrence of
another type.
oLifetime secondary effects
Anxiety
Depression
Suicidal ideation
MDD & PTSD
- Risk Factors
oChild is seen as different.
oChild is seen as fragile.
oChild reminds parent of someone they dislike.
oChild does not live up to parents’ fantasy.
oChild is the result of unwanted pregnancy.
oChild whose emotional bonding was interrupted due to prematurity or
prolonged illness.
Characteristics of Abusive Parents
- History of childhood abuse or neglect
- Family authoritarianism; harsh punishments
- Low self-esteem, social isolation, and poor coping skills, low frustration tolerance
- Experiencing a crisis
- Unrealistic expectations of the child
- Severe mental illness or substance use disorder.
- Poor impulse control or violent temper
Older Adult Abuse
- Mistreatment
oFailure to provide basic needs.
oFailure to protect.
- Physical or sexual abuse
- Financial abuse
- Epidemiology
oFamily
oCustodial/care personnel
Risk Factors
- Poor mental or physical health
- Disruptive due to a disorder (Alzheimer’s)
- Dependent on perpetrator
- Female, older than 75 years, white, living with a relative while impaired.
- Elderly parents cared for by children or spouses they abused earlier in life.
Nursing Process
- General Assessment
oHistory of sexual abuse, family violence, and drug use or abuse
- Interview process and setting
oAvoid words like “abuse” or “violence.”
oAsk how disagreements are settled, how children are disciplined.
oAvoid assumptions about a person’s sexual orientation.
- Self-assessment
Assessment
- Should include:
oViolence indicators
oLevel of anxiety and coping responses
oFamily coping patterns
oSupport systems
oSuicide and/or homicide potential
oDrug and alcohol use
- Signs of Sexual Abuse in Children
oSexualized behavior
oPrecocious sexual knowledge/ explicit talk or images/demonstration of sexual
aggression
oActing out sexual interactions
oMasturbation
oSexual promiscuity in older children
oPTSD symptoms
oSomatic complaints
oFeelings of guilt
Assessment
- Emotional abuse
oLow self-esteem, reported feelings of inadequacy, anxiety and withdrawal,
learning difficulties, and poor impulse control.
- Neglect
oAppear undernourished, dirty, and poorly clothed; inadequate medical care such
as lack of immunizations and untreated medical or dental conditions.
- Economic Abuse
oFailure to provide needs.
- Assessment Variables
oAnxiety
oCoping mechanisms
oSupport systems
oSuicide potential
oHomicide potential
oDrug and alcohol use
- Assessment Documentation
oVerbatim statement of who and when
oBody map to indicate size, color, shape, areas, and types of injuries with
explanations.
oPhysical evidence of sexual abuse, when possible
- Self-Assessment
oIntense and overwhelming feelings
oStrong negative feelings may cloud judgment and interfere with objective
assessment and intervention.
oCommon responses of healthcare professionals to violence
Application of the Nursing Process
- Nursing Diagnosis (Table 28.4)
oDirected toward protecting vulnerable family members.
oCan also include perpetrator in plans of care.
- Outcomes identification
oReduce or reverse the problem addressed.
Planning
-Joint Commission Guidelines Require—
-Staff education in family violence and abuse
-Development of standards of care to guide clinical practice.
-Protocol for Planning
oPatient’s safety first
oDiscuss with patient if possible; child removed to safe place.
Implementation
-Reporting abuse
-Considering family’s culture
-Case management
-Promotion of community support
-Health teaching and health promotion
Prevention of Abuse
- Primary prevention
oMeasures taken to prevent the occurrence of abuse.
- Secondary prevention
oEarly intervention in abusive situations to minimize their disabling or long-term
effects.
- Tertiary prevention
oFacilitating the healing and rehabilitative process
oProviding support
oAssisting survivors of violence to achieve their optimal level of safety, health, and
well-being.
Evaluation: Questions to Consider
- Is corporal punishment an acceptable technique for guiding behavior in children?
- How do we address the unequal burden of caregiving responsibilities placed on women?
- Why is a low priority given to education and preparation for parenthood?
- How can we change the belief that older adults have little social value?
Treatment Modalities- Psychological Therapies
- Individual therapy
- Family therapy
- Group therapy
Family Dynamics
- Family dynamics is defined as
oInterrelationships between and among individual family members OR
oThe forces at work within a family that produce particular behaviors or
symptoms.
Statistics on Aging
- Life expectancy and number of older adults growing
- Common classifications for older adults:
oYoung-old: 65 to 74 years
oMiddle-old: 75 to 84 years
oOld-old: 85 to 100 years
oCentenarians: 100 to 104 years
Mental Health and Aging
- Late-life Mental Illness
- Major Depressive Disorder
- Suicide
- Major Depressive Disorder
- Suicide
- Anxiety disorders
- Delirium—secondary to general medical condition
- Neurocognitive disorders
- Alcohol use disorder
- Pain
Pain
-Barriers to accurate pain assessment
-Assessment tools
oWong-Baker FACES Pain Rating Scale
oPain Assessment in Advanced Dementia (PAINAD) scale
-Pain management
oPharmacotherapy
Non-opioids
Opioids
oNonpharmacological pain treatments
Healthcare Concerns of the Older Adults
- Financial burden
- Medicare Part D for help with medications
- Caregiver burden
- Ageism
oLanguage
oPublic policy
oResearch
Healthcare Decision Making
- Advance Directives and Portable Medical Orders
oAdvance Directives and Portable Medical Orders
- Guardianship
oCourt-ordered relationship in which the selected guardian acts on behalf of
another individual (the ward)
oThe ward must be proven to lack capacity to manage personal and/or financial
affairs.
Application of the Nursing Process
- Assessment
oPrivate interview space
oAdequate lighting & low-level noise
oEstablish rapport & convey warmth.
oPhysical Assessment
oMedication reconciliation
Polypharmacy & prescribing cascades
oMental Status exam
oOlder adult drivers
oOlder adult abuse
- Nursing Diagnosis
oThe International Classification for Nursing Practice (ICNP) (International Council
of Nurses)
Provides useful nursing diagnoses for older adults.
Acute/chronic pain, impaired low nutrition intake, impaired fluid intake,
constipation, and impaired sleep
Safety needs
Higher level needs
Caregiver stress/impaired family process
- Outcomes Identification
oShared decision making; realistic goals.
- Implementation
oPsychotherapeutic Methods
oEmpathetic, active listening to encourage ventilation of feelings & reestablish
emotional equilibrium.
oProvide health education & alternatives.
oAssist in problem solving.
oGroup counseling to help build relationships and reduce isolation.
oPharmacotherapy skills & psychotherapy
- Treatment Modalities
oPsychological Therapies
Treatment Settings for Older Adults
- Hospital-Based Care
oPartial hospitalization versus Inpatient
