Abuse and Neglect

1. Abuse and Neglect Constance H. Fournier Clinical Professor Texas A & M University

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. Risk Factors • Having few friends • Absent or unavailable parents • Step family • Conflict with or between parents • Physical or intellectual disability

11. 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

12. 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)

13. 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

14. Negative effects: Physical • Risk of HIV infection • Risk of STIs • Pregnancy • Physical impact on organs

15. 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

16. 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

17. Physical Consequences: Physical Abuse • Minor • Bruises • Cuts • Burns • Major • Broken bones • Ruptures • Hemorrhage • death

18. 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

19. 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

20. 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

21. 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

22. Factitious Disorder by Proxy • Factitious disorder with mostly psychological symptoms • Confusion • Auditory hallucinations • Bizarre behavior • Was called GanserSymdrome (prison psychosis)

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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)

29. 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

30. 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.

31. 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

32. 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

33. 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

34. Resources • 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