Violence is not a new problem; in fact, it is probably as old as humankind. However, in the United States, medicine has focused on these issues only since 1946. Therefore, the parameters of abuse are being identified and redefined on what seems to be an almost daily basis. For example, until recently women and children were considered the personal property of men and they did not own property or have rights of their own. Women viewed themselves as sexual objects and were expected to subjugate themselves/defer to the will of men. Harsh treatment of children was justified by the belief that corporal and/or excessive punishment was necessary to maintain discipline and instill values. Changes in societal beliefs and the enactment of new laws have done little to curb abuse. Today, battering is the single most common cause of injury to women, and there has been an increase in the incidence of child abuse and neglect-related fatalities reported to child protection service agencies in the United States. Whether these statistics represent an increase in incidents or are the result of changing attitudes and/or better reporting is much debated. The Centers for Disease Control and Prevention has declared violence to be a public health problem.
This plan of care addresses the problems of abuse and neglect in both adults and children and includes both the person who offends and the survivor of the offense.
IF FOCUS OF ATTENTION IS ON THE VICTIM [SURVIVOR]:
995.52 Neglect of child
995.53 Sexual abuse of child
995.54 Physical abuse of child
995.81 Physical abuse of adult
995.83 Sexual abuse of adult
IF FOCUS OF ATTENTION IS ON THE PERPETRATOR [OFFENDER] OR ON THE RELATIONAL
UNIT IN WHICH BEHAVIOR OCCURS:
V61.21 Neglect; physical or sexual abuse of child (specify)
V61.12 (Physical or sexual abuse of adult by partner)
V62.83 (Physical or sexual abuse of adult by person other than partner)
Psychoanalytical theory suggests that unmet needs for satisfaction and security result in an underdeveloped ego and a poor self-concept in the individuals involved in violent episodes. Aggression and violence supply the offender with a sense of power and prestige that boosts the self-image and provides a significance or purpose to the individual’s life that is lacking. Some theorists have supported the hypothesis that aggression and violence are the overt expressions of powerlessness and low self-esteem. The same dynamics promote acceptance in the person who is the victim of violence.
Various components of the neurological system have been implicated in both the facilitation and inhibition of aggressive impulses. The limbic system in particular appears to be involved. In addition, higher brain centers play an important role by constantly interacting with the aggression centers. Various neurotransmitters, such as epinephrine, norepinephrine, dopamine, acetylcholine, and serotonin, may also play a role in facilitation and inhibition of aggressive impulses. This theory is consistent with the “fight-orflight” arousal in response to stress.
Some studies suggest the possibility of a direct genetic link; however, the evidence for this has not been firmly established. Organic brain syndromes associated with various cerebral disorders have been linked to violent behavior. Particularly, areas of the limbic system and temporal lobes, brain trauma, and diseases such as encephalitis and disorders such as epilepsy have been implicated in aggressive behavior.
Child abuse is often the consequence of the interactions of parental vulnerabilities (e.g., mental illness, substance abuse); child vulnerabilities (e.g., low birth weight, difficult temperament); a particular developmental stage, such as toddler, adolescence; and social stressors (e.g., lack of social supports, young parental age, single parenthood, poverty, minority ethnicity, lack of acculturation, exposure to family violence).
Learning theory states that children learn to behave by imitating their role models, usually parents, although as they mature they are influenced by teachers, friends, and others. Individuals who were abused as children or whose parents disciplined them with physical punishment are more likely to behave in a violent manner as adults. Television and movies are believed to have an influence on developing both adaptive and maladaptive behavior. Some theorists believe that individuals who have a biological influence toward aggressive behavior are more likely to be affected by external models than those without this predisposition.
The influence of culture and social structure cannot be discounted. Difficulty in negotiating interpersonal conflict has led to a general acceptance of violence as a means of solving problems. When individuals /groups of people discover they cannot meet their needs through conventional methods, they are more likely to resort to delinquent behaviors. This may contribute to a subculture of violence within society.
1. Provide physical/emotional safety.
2. Develop a trusting therapeutic relationship.
3. Enhance sense of self-esteem.
4. Improve problem-solving ability.
5. Involve family/partner in therapeutic program.
1. Physical/emotional safety maintained.
2. Trusting relationship with one person established.
3. Self-growth and positive approaches to problems evident.
4. Client/SOs participating in ongoing therapy.
5. Plan in place to meet needs after discharge.
Nursing diagnosis for Problems Related to Abuse or Neglect: Risk for Trauma may be related to Dependent position in relationship(s); History of previous abuse/neglect; and Lack or nonuse of support systems/resources.
1. Be free of injury/signs of neglect.
2. Recognize need for/seek assistance to prevent abuse.
3. Identify and access resources to assist in promoting a safe environment.
Nursing intervention with rationale:
1. Note age/developmental level of survivor, mentation, agility, physical abilities/limitations.
Rationale: Children under 3, those perceived as having different temperament, or those with congenital problems /chronic illness are at increased risk of being abused/neglected. Additionally, the elderly who are dependent on others because of age/ infirmities or individuals with significant disabilities are also at risk. Those who are incapable of meeting their own needs/directing their personal affairs may require alternate placement/court-ordered advocate.
2. Review physical complaints/injuries including those that suggest possibility of sexual abuse (e.g., bladder infection, bruises in the genital area, reports of aggression or inappropriate sexual behavior). Note affect and demeanor.
Rationale: The visible evidence of physical abuse/neglect makes it more easily recognized. Although these clients display signs of emotional involvement, inappropriate affect, and behaviors such as withdrawal, acting out, or suicidal gestures in the absence of physical evidence of abuse/neglect, suggests presence of emotional abuse. Child sexual abuse is particularly difficult to diagnose. Although the signs noted here are not definitive, they suggest need for further investigation.
3. Identify individual concerns of client.
Rationale: Concerns will vary dependent on individual circumstances and affect choice of interventions, possible options.
4. Interview offender(s)/family in a nonjudgmental manner, displaying tact and professional concern for individual(s).
Rationale: Can provide insight into risks to client and potential for repetition of behavior. The need for power over or control of survivor, excessive jealousy/overpossessiveness, frequency of verbal arguments that can escalate to violence, substance abuse, severity of past injuries inflicted, history of forced or threatened sexual acts, and/or threats to kill client (especially when offender indicates a belief he or she cannot live without partner) greatly increases the level of concern for survivor’s safety and choice of interventions.
5. Maintain objectivity and avoid blame or accusations during interview process.
Rationale: Individuals will be defensive and may react with hostility and anger, or may withdraw, making it difficult to obtain accurate information. Initially, offender may not be known, and even if family is not involved in situation, members may feel guilt that they did not protect the survivor. Avoiding blame promotes open communication and therapeutic interactions and may enhance the investigation process.
6. Use open-ended questions with gentle, caring manner. Speak at individual’s level (e.g., child vs. adult, or developmentally disabled individual). Provide privacy as indicated by age, circumstances of the situation.
Rationale: Survivor and parent/family members will respond more positively to caring approach and be more available for help to correct underlying problems when dealt with in this way. Note: Care must be taken to avoid leading the child survivor, or suggesting answers to questions. As these individuals are vulnerable, they are suggestible and may provide answers to “please” the therapist, resulting in questionable information.
7. Use techniques of play therapy to obtain information from children. Videotape session(s) as appropriate.
Rationale: The child may be afraid to tell/be unable to adequately verbalize what has happened. Play therapy is a nonthreatening method of observation/Active-listening that allows for free expression of the child’s feelings and perceptions without undue influence from adults. Videotaping allows various parties (legal and counseling) to view the same data, reducing risk of misinterpretation and negating need for child to submit to repeated questioning, which may color data over time. In addition, this can provide safeguards for both therapist and survivor.
8. Note sequence of events as related by parent(s)/ caregivers or partner, paying particular attention to inconsistencies and contradictory reports.
Rationale: May reveal reality of what happened. Offender(s)/family members are upset and afraid about what has happened/the potential consequences and may try to cover up circumstances of injury.
9. Evaluate family and home environment. Note particularly areas of stress related to abusive occurrence.
Rationale: Provides clues to need for change to prevent further problems. Families who move their residence frequently and are socially isolated, and stepfamilies are at greater risk. Children who have been separated from parents because of prematurity or neonatal illness also may be more at risk, owing in part to problems with bonding and situational stressors (e.g., financial concerns, demands of caregiving role).
10. Refer to individual/family therapy.
Rationale: As in the case of violent behavior, involved individuals need to distinguish between validity of emotions and the inappropriateness of behavior. Violence is the choice of the offender, is under his or her control, and is his or her sole responsibility although the dynamics of relationship(s) may be a factor.