DSM-IV
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)
Abuse affects all populations and is not restricted to specific socioeconomic or ethnic/cultural groups. Although “violence” means the use of force or physical compulsion to abuse or damage, the term “abuse” is much broader and includes physical or mental maltreatment and neglect that result in emotional, physical, or sexual injury. In the case of children, the disabled, or elderly, abuse can result from direct actions or omissions by those responsible for the individual’s care. Additionally, one’s perception of abuse is affected by cultural and religious practices, values, and biological predispositions. The problem can be generational, with victimizers often being victims of abuse themselves as children.
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.
ETIOLOGICAL THEORIES
Psychodynamics
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.
Biological
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-or-flight” 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.
Family Dynamics
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.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Sleep problems (e.g., sleeplessness or oversleeping, nightmares, sleepwalking, sleeping in strange place [avoiding offender])
Fatigue
Ego Integrity
Negative self-appraisal, acceptance of self-blame/making excuses for the actions of others
Low self-esteem (offender/survivor)
Feelings of guilt, anger, fear and shame, helplessness, and/or powerlessness
Minimization or denial of significance of behaviors (most prominent defense mechanism)
Avoidance or fear of certain people, places, objects; submissive, fearful manner (particularly in presence of offender)
Report of stress factors (e.g., family unemployment; financial, lifestyle changes; marital discord)
Hostility toward/mistrust of others
Threatened when partner shows signs of independence or shares self/time with others (offender)
Elimination
Enuresis, encopresis
Recurrent urinary infections
Changes in tone of sphincter
Food/Fluid
Frequent vomiting; changes in appetite: anorexia, overeating (survivor)
Changes in weight; failure to gain weight appropriately/signs of malnutrition, repeated pica (neglect)
Hygiene
Wearing clothing that covers body in a manner inappropriate for weather conditions (abuse), or that is inadequate to provide protection (neglect)
Excessive/anxiety about bathing (abuse); dirty/unkempt appearance (neglect)
Neurosensory
Behavioral extremes (very aggressive/demanding conduct); extreme rage or passivity and withdrawal; age-inappropriate behavior
Mental Status:
Memory: Blackouts, periods of amnesia; reports of flashbacks
Disorganized thinking; difficulty concentrating/making decisions
Inappropriate affect; may be hypervigilant, anxious, depressed
Mood swing—“dual personality,” extremely loving, kind, contrite after battering episode (offender)
Pathological jealousy; poor impulse control; limited coping skills; lacks empathy (offender)
Rocking, thumb sucking, or other habitual behavior; restlessness (survivor)
Psychiatric manifestations (e.g., dissociative phenomena including multiple personalities (sexual abuse); borderline personality disorder [adult incest survivors])
Presence of neurological deficits/CNS damage without external injuries evident (may indicate “shaken baby” syndrome)
Pain/Discomfort
Dependent on specific injuries/form of abuse
Multiple somatic complaints (e.g., stomach pain, chronic pelvic pain, spastic colon, headache)
Safety
Bruises, bite marks, skin welts, burns (e.g., scalding, cigarette), bald spots, lacerations, unusual bleeding, rashes/itching in the genital area; anal fissures, skin tags, hemorrhoids, scar tissue, changes in tone of sphincter
Recurrent injuries; history of multiple accidents, fractures/internal injuries
Description of incident incongruent with injury, delay in seeking treatment
Lack of age-appropriate supervision, inattention to avoidable hazards in the home (neglect)
Intense episodes of rage directed at self or others
Self-injurious/suicidal behavior; involvement in high-risk activities
History of suicidal behavior of family members
Sexuality
Changes in sexual awareness or activity, including compulsive masturbation, precocious sex play, tendency to repeat or reenact incest/abuse experience; excessive curiosity about sex; sexually abusing another child; promiscuity; overly anxious/ inhibited about sexual anatomy or behavior
May display feminine sex-role stereotypes; confusion about sexuality (male survivors); may have unconscious homosexual tendencies (male offenders of incest)
Reports of decreased sexual desire (as adult), erectile dysfunction, premature ejaculation, and/or anorgasmia; dyspareunia, vaginismus; flashbacks during intercourse; inability to engage in sex without anxiety
Episodes of marital rape or forced intercourse
Impaired sexual relationship between parents (incest)
Parent/female careprovider aware or strongly suspects incestual behavior, may be grateful not to be focus of partner’s sexual demands
Obstetrical history of preterm labor, abruptio placentae, spontaneous abortions, low birth weight, fetal injury/death (1 in 6 pregnant women are battered during pregnancy); lack of prenatal care until 3rd trimester (abused women twice as likely to delay care)
Vaginal bleeding; linear laceration of hymen, vaginal mucosa
Presence of STDs, vaginitis, genital warts, or pregnancy (especially child)
Social Interactions
Multiple family/relationship stressors reported
Household members may include step-relatives or a paramour
History of frequent moves/relocation
Few/no support systems
Lacks knowledge of appropriate child-rearing practices (child abusers)
Inability to form satisfactory peer relationships; withdrawal in social settings; inappropriate attachment to imaginary companion
Very possessive, perceives partner as a possession; repeatedly insults/humiliates partner, strives to isolate partner from others/keeps partner totally dependent, challenges partners honesty, uses intimidation to achieve power/control over partner (offender)
Lack of assertive communication skills; difficulty negotiating interpersonal conflicts
Cheating, lying; low achievement or drop in school performance
Running away from home/relationship
Parent may interfere with child’s normal peer relationships to prevent exposure (incest)
Memories of childhood may contain blank periods, excessive fantasizing/daydreaming; report of violence/neglect in family of origin
Family Interaction Pattern: Less verbally responsive, increased use of direct commands and critical statements, decreased verbal praise or acknowledgment, belittling, denigrating, scapegoating, ignoring; significant imbalance of power/use of hitting as control measure, patterns of enmeshment, closed family system; one parent domineering, impulsive; other partner passive, submissive
Teaching/Learning
May be any age, race, religion/culture, or educational level; from all socioeconomic groups (usual child profile is under age 3 or perceived as different due to temperamental traits, congenital abnormalities, chronic illness)
Learning disabilities include attention-deficit disorders, conduct disorders
Delay in achieving developmental tasks, declines on cognitive testing; brain damage, habitual truancy/absence from school for nonlegitimate reasons (neglect)
Substance abuse by individuals involved in abuse/neglect, or other family member(s) (most often cocaine, crack, amphetamines, alcohol)
Use of multiple healthcare providers/resources (limits awareness of repeated nature of problem); lack of age-appropriate health screening/immunization, dental care, absence of necessary prostheses, such as eyeglasses, hearing aid (neglect)
DIAGNOSTIC STUDIES
Physical and Psychological Testing
dependent on individual situation/needs
Screening Tests (e.g., Child Behavior Checklist): Elevated scores on the internalization scale reveal behaviors described as fearful, inhibited, depressed, overcontrolled or undercontrolled, aggressive, antisocial.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
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)
Abuse affects all populations and is not restricted to specific socioeconomic or ethnic/cultural groups. Although “violence” means the use of force or physical compulsion to abuse or damage, the term “abuse” is much broader and includes physical or mental maltreatment and neglect that result in emotional, physical, or sexual injury. In the case of children, the disabled, or elderly, abuse can result from direct actions or omissions by those responsible for the individual’s care. Additionally, one’s perception of abuse is affected by cultural and religious practices, values, and biological predispositions. The problem can be generational, with victimizers often being victims of abuse themselves as children.
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.
ETIOLOGICAL THEORIES
Psychodynamics
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.
Biological
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-or-flight” 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.
Family Dynamics
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.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Sleep problems (e.g., sleeplessness or oversleeping, nightmares, sleepwalking, sleeping in strange place [avoiding offender])
Fatigue
Ego Integrity
Negative self-appraisal, acceptance of self-blame/making excuses for the actions of others
Low self-esteem (offender/survivor)
Feelings of guilt, anger, fear and shame, helplessness, and/or powerlessness
Minimization or denial of significance of behaviors (most prominent defense mechanism)
Avoidance or fear of certain people, places, objects; submissive, fearful manner (particularly in presence of offender)
Report of stress factors (e.g., family unemployment; financial, lifestyle changes; marital discord)
Hostility toward/mistrust of others
Threatened when partner shows signs of independence or shares self/time with others (offender)
Elimination
Enuresis, encopresis
Recurrent urinary infections
Changes in tone of sphincter
Food/Fluid
Frequent vomiting; changes in appetite: anorexia, overeating (survivor)
Changes in weight; failure to gain weight appropriately/signs of malnutrition, repeated pica (neglect)
Hygiene
Wearing clothing that covers body in a manner inappropriate for weather conditions (abuse), or that is inadequate to provide protection (neglect)
Excessive/anxiety about bathing (abuse); dirty/unkempt appearance (neglect)
Neurosensory
Behavioral extremes (very aggressive/demanding conduct); extreme rage or passivity and withdrawal; age-inappropriate behavior
Mental Status:
Memory: Blackouts, periods of amnesia; reports of flashbacks
Disorganized thinking; difficulty concentrating/making decisions
Inappropriate affect; may be hypervigilant, anxious, depressed
Mood swing—“dual personality,” extremely loving, kind, contrite after battering episode (offender)
Pathological jealousy; poor impulse control; limited coping skills; lacks empathy (offender)
Rocking, thumb sucking, or other habitual behavior; restlessness (survivor)
Psychiatric manifestations (e.g., dissociative phenomena including multiple personalities (sexual abuse); borderline personality disorder [adult incest survivors])
Presence of neurological deficits/CNS damage without external injuries evident (may indicate “shaken baby” syndrome)
Pain/Discomfort
Dependent on specific injuries/form of abuse
Multiple somatic complaints (e.g., stomach pain, chronic pelvic pain, spastic colon, headache)
Safety
Bruises, bite marks, skin welts, burns (e.g., scalding, cigarette), bald spots, lacerations, unusual bleeding, rashes/itching in the genital area; anal fissures, skin tags, hemorrhoids, scar tissue, changes in tone of sphincter
Recurrent injuries; history of multiple accidents, fractures/internal injuries
Description of incident incongruent with injury, delay in seeking treatment
Lack of age-appropriate supervision, inattention to avoidable hazards in the home (neglect)
Intense episodes of rage directed at self or others
Self-injurious/suicidal behavior; involvement in high-risk activities
History of suicidal behavior of family members
Sexuality
Changes in sexual awareness or activity, including compulsive masturbation, precocious sex play, tendency to repeat or reenact incest/abuse experience; excessive curiosity about sex; sexually abusing another child; promiscuity; overly anxious/ inhibited about sexual anatomy or behavior
May display feminine sex-role stereotypes; confusion about sexuality (male survivors); may have unconscious homosexual tendencies (male offenders of incest)
Reports of decreased sexual desire (as adult), erectile dysfunction, premature ejaculation, and/or anorgasmia; dyspareunia, vaginismus; flashbacks during intercourse; inability to engage in sex without anxiety
Episodes of marital rape or forced intercourse
Impaired sexual relationship between parents (incest)
Parent/female careprovider aware or strongly suspects incestual behavior, may be grateful not to be focus of partner’s sexual demands
Obstetrical history of preterm labor, abruptio placentae, spontaneous abortions, low birth weight, fetal injury/death (1 in 6 pregnant women are battered during pregnancy); lack of prenatal care until 3rd trimester (abused women twice as likely to delay care)
Vaginal bleeding; linear laceration of hymen, vaginal mucosa
Presence of STDs, vaginitis, genital warts, or pregnancy (especially child)
Social Interactions
Multiple family/relationship stressors reported
Household members may include step-relatives or a paramour
History of frequent moves/relocation
Few/no support systems
Lacks knowledge of appropriate child-rearing practices (child abusers)
Inability to form satisfactory peer relationships; withdrawal in social settings; inappropriate attachment to imaginary companion
Very possessive, perceives partner as a possession; repeatedly insults/humiliates partner, strives to isolate partner from others/keeps partner totally dependent, challenges partners honesty, uses intimidation to achieve power/control over partner (offender)
Lack of assertive communication skills; difficulty negotiating interpersonal conflicts
Cheating, lying; low achievement or drop in school performance
Running away from home/relationship
Parent may interfere with child’s normal peer relationships to prevent exposure (incest)
Memories of childhood may contain blank periods, excessive fantasizing/daydreaming; report of violence/neglect in family of origin
Family Interaction Pattern: Less verbally responsive, increased use of direct commands and critical statements, decreased verbal praise or acknowledgment, belittling, denigrating, scapegoating, ignoring; significant imbalance of power/use of hitting as control measure, patterns of enmeshment, closed family system; one parent domineering, impulsive; other partner passive, submissive
Teaching/Learning
May be any age, race, religion/culture, or educational level; from all socioeconomic groups (usual child profile is under age 3 or perceived as different due to temperamental traits, congenital abnormalities, chronic illness)
Learning disabilities include attention-deficit disorders, conduct disorders
Delay in achieving developmental tasks, declines on cognitive testing; brain damage, habitual truancy/absence from school for nonlegitimate reasons (neglect)
Substance abuse by individuals involved in abuse/neglect, or other family member(s) (most often cocaine, crack, amphetamines, alcohol)
Use of multiple healthcare providers/resources (limits awareness of repeated nature of problem); lack of age-appropriate health screening/immunization, dental care, absence of necessary prostheses, such as eyeglasses, hearing aid (neglect)
DIAGNOSTIC STUDIES
Physical and Psychological Testing
dependent on individual situation/needs
Screening Tests (e.g., Child Behavior Checklist): Elevated scores on the internalization scale reveal behaviors described as fearful, inhibited, depressed, overcontrolled or undercontrolled, aggressive, antisocial.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
Chinese
French
German
Italian
Japanese
Korean
Russian
Spanish
