Child, older adult, and intimate partner violence

Judi Sateren

Objectives

1. Identify the nature and scope of family violence and factors contributing to its occurrence.

2. Identify three indicators of (a) physical abuse, (b) sexual abuse, (c) neglect, and (d) emotional abuse.

3. Describe risk factors for both victimization and perpetration of family violence.

4. Describe four areas to assess when interviewing a person who has experienced abuse.

5. Identify two common emotional responses the nurse might experience when faced with a person subjected to abuse.

6. Formulate four nursing diagnoses for the survivor of abuse, and list supporting data from the assessment.

7. Write out a safety plan for a victim of intimate partner abuse.

8. Discuss the legal and ethical responsibilities of nurses when working with families experiencing violence.

9. Compare and contrast primary, secondary, and tertiary levels of intervention, giving two examples of intervention for each level.

10. Describe at least three possible referrals for an abusive family, including the telephone numbers of appropriate agencies in the community.

11. Discuss three psychotherapeutic modalities useful in working with abusive families.

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There’s no place like home. This is a statement familiar to most of us, and home is considered by many to be a source of refuge and peace. Yet for many children, adults, and elders the home is a dangerous place where family members or intimate partners demonstrate complete disregard for the rights of others. Family violence (also called domestic violence) is among the most important public health issues in the United States. Nurses are in a unique position to respond to family violence and are educated to identify, evaluate, and treat both victims and perpetrators of violence.

The American Academy of Family Physicians defines family violence as the “intentional intimidation, abuse, or neglect of children, adults, or elders by a family member, intimate partner, or caretaker in order to gain power and control over the victim” (2008, para. 1). Legal definitions of family or domestic violence vary from state to state; 46 states have specific definitions in their civil statutes (U.S. Department of Health and Human Services [USDHHS], 2011).

Specific types of abuse have been identified as physical abuse, sexual abuse, emotional abuse, neglect, and economic abuse. Physical abuse is the infliction of physical pain or bodily harm (e.g., slapping, punching, hitting, choking, pushing, restraining, biting, throwing, and burning). Sexual abuse is any form of sexual contact or exposure without consent, or in circumstances in which the victim is incapable of giving consent. Sexual abuse is also referred to as sexual assault or rape and is discussed in Chapter 29. Emotional abuse is the infliction of mental anguish (e.g., threatening, humiliating, intimidating, and isolating). Neglect is the failure to provide for physical, emotional, educational, and medical needs. Economic abuse is controlling a person’s access to economic resources. Each of these types of abuse will be addressed in more depth in this chapter.

Epidemiology

It is estimated that half of all people in the United States have experienced abuse in their families. While the true prevalence of child, elder, and intimate partner abuse is unknown because of underreporting and variability in reporting methods, instruments, sites, and reporters, it is clear that abuse is a significant problem.

Child abuse

In 2010 there were 3.3 million referrals for child abuse, 20% of which were substantiated (USDHHS, 2011). The most common form of abuse was neglect (78%), followed by physical abuse (17%), sexual abuse (9%), and emotional abuse (8%). Table 28-1 gives statistics related to abuse rates and fatalities among different ethnicities.

TABLE 28-1

VICTIMS OF ABUSE AND FATALITIES AMONG DIFFERENT ETHNICITIES: 2010

RACE OR ETHNICITY	% OF TOTAL ABUSE CASES	% OF TOTAL CHILD FATALITIES
African American	21.9%	28.1%
American Indian or Alaska Native	1.1%	0.8%
Children of multiple races	3.5%	4.4 %
Hispanic	21.4%	16.6%
White	44.8%	43.6%
Asian	0.9%	0.9%

Data from the U.S. Department of Health & Human Services. (2011). Child maltreatment 2010. Washington, DC: U.S. Government Printing Office.

Girls are slightly more likely to be abused, comprising 51% of victims. In general, the younger the child the more vulnerable she or he is to abuse. Tragically, children under the age of 1 account for about 21% of all abuse cases (USDHHS, 2011). Approximately 80% of children who die are younger than 4 years of age, and boys die at a slightly higher rate than girls. The abuse of neglect is the most common cause of death. The prevalence of sexual abuse in children is difficult to determine due to the fact that children are often unable to describe their experience. Relatively uncommon in infants, sexual abuse increases with age. Beginning at puberty, the rate of sexual abuse is about 9% of all abuse cases (USDHHS, 2011).

It is estimated that 80% of perpetrators are the victim’s parents (USDHHS, 2011). Mothers abuse more frequently and account for 37% of cases, fathers acting alone account for 19% of abuse cases, both parents as abusers occurs in 18% of cases, and in 7% of the cases the abusers are a parent along with another person.

Intimate partner abuse

According to the National Intimate Partner and Sexual Violence Survey (Black et al., 2011), more than 1 in 3 women and 1 in 4 men have experienced physical violence, rape, and/or stalking by an intimate partner at some time in their lives. Females are victimized about 6 times more often than males. In persons aged 12 and older, about 4 females per 1000 persons report abuse while males report abuse at a rate of 0.8 per 1000 persons (U.S. Bureau of Justice Statistics, 2007).

The gender gap of physical violence in intimate partner relationships seems to be narrower. Nearly 1 in 3 women and 1 in 4 men have been slapped, pushed, or shoved by an intimate partner in their lifetimes (Black et al., 2011). Nearly half of married couples have instances of abuse, and evidence suggests that intimate partner violence affects same-sex relationships at about the same rates as heterosexual relationships (Stephenson et al., 2011). One out of 10 homicides is due to spousal murder, and about a third of females who are killed are or were in an intimate relationship with their killer.

Older adult abuse

According to the American Psychological Association (APA) (2012), every year about 2 million older adults in the United States are reported to be physically abused, psychologically abused, or neglected. The APA suggests that the number may be far higher and that for every case reported, five go unreported. Further complicating the picture is that the older adult may be caring for himself or herself, which creates the potential for self-neglect. Elder abuse occurs in both institutional and family settings. Family members are reported to be the perpetrators in about 76% of incidents (Acierno et al., 2010).

VIGNETTE

Walter, a 73-year-old man, came to the ambulatory care clinic looking very fatigued and complaining of pain in his left shoulder “since last night.” Holding his left arm close to his side, Walter averted his eyes from those of the receptionist, nurse, and doctor. When asked if anything had occurred that might have caused the pain, he answered, “I fell.” Asked why he had not sought care the previous night, Walter stated, “I …. thought it would go away overnight.” Upon further examination and X-ray imaging, it was determined that the patient had sustained a fractured clavicle. Additional direct, supportive questioning elicited the information that the patient had been injured when pushed to the floor by his son.

Comorbidity

The occurrence of one type of abuse is a fairly strong predictor of the occurrence of another type. The secondary effects of abuse, such as anxiety, depression, and suicidal ideation, are health care issues that can last a lifetime. Depression and posttraumatic stress disorder (PTSD) are two of the most prevalent disorders resulting from childhood trauma. Family violence is common in the childhood histories of juvenile offenders, runaways, violent criminals, prostitutes, and those who in turn are violent toward others. Exposure to abuse can adversely affect a child’s development because the energy needed to successfully accomplish developmental tasks goes instead to coping with abuse (Bensley et al., 2003; Desai et al., 2002).

Abused adolescents exhibit more psychopathological changes, poorer coping and social skills, a higher incidence of dissociative identity disorder, and poorer impulse control than do other adolescents. Women who are victims of prolonged childhood sexual abuse are more likely to develop major psychiatric distress. Box 28-1 identifies some of the long-term effects of family violence.

BOX 28-1 LONG-TERM EFFECTS OF FAMILY VIOLENCE

People involved in family violence are found to have a higher incidence of:

• Inability to develop intimate relationships in later life

Victims of severe violence are also at higher risk for experiencing recurring symptoms of posttraumatic stress disorder:

• Flashbacks

• Dissociation—out-of-body experiences

• Poor self-esteem

• Compulsive or impulsive behaviors (e.g., substance abuse, excessive spending, gambling, and promiscuity)

• Multiple somatic complaints

Children who witness violence in their homes:

• After the age of 5 or 6 years show an indication of identifying with the aggressor and losing respect for the victim.

• Are at greater risk for developing behavioral and emotional problems throughout their lives.

Some mental and behavioral disorders are associated with violence in childhood:

• Depressive disorders

• Posttraumatic stress disorder

• Somatic complaints, technically not a “disorder”

• Low self-esteem, same as above

• Phobias (agoraphobia, social and specific phobias)

• Antisocial behaviors

• Child or spouse abuse

Adolescents are more likely to have behavioral symptoms such as:

• Failing grades

• Difficulty forming relationships

• Increased incidence of theft, police arrest, and violent behaviors

• Seductive or promiscuous behaviors

• Running away from home

Etiology

Environmental factors

Abuse occurs across all segments of society in the United States. Social factors that reinforce violence include the wide acceptance of corporal punishment; increasingly violent movies, video games, websites, and comic books; violent themes in music; and the increase in the total volume of pornography.

The occurrence of abuse requires the following participants and conditions:

1. A perpetrator

2. Someone who by age or situation is vulnerable (children, women, older adults, and mentally ill or physically challenged persons)

3. A crisis situation

Perpetrator

The propensity for violence is rooted in childhood and manifested by a general lack of self-regard, dissatisfaction with life, and inability to assume adult roles. Often the abuser lacked good role models and was deprived of the opportunity to develop problem-solving skills. Witnessing or experiencing family violence, neglect, or abusive parenting (Box 28-2) are contributing factors. Perpetrators, those who initiate violence, often consider their own needs to be more important than anyone else’s and look toward others to meet their needs.

BOX 28-2 CHARACTERISTICS OF ABUSIVE PARENTS

• A history of abuse, neglect, or emotional deprivation as a child

• Family authoritarianism: raise children as they were raised by their own parents

• Low self-esteem, feelings of worthlessness, depression

• Poor coping skills

• Social isolation (may be suspicious of others): few or no friends, little or no involvement in social or community activities

• Involvement in a crisis situation: unemployment, divorce, financial difficulties

• Rigid, unrealistic expectations of child’s behavior

• Frequent use of harsh punishment

• History of severe mental illness, such as schizophrenia

• Violent temper outbursts

• Looking to child for satisfaction of needs for love, support, and reassurance (often unmet because of parenting deficits in family of origin)

• Projection of blame onto the child for parents’ “troubles” (e.g., stepparent may project hostility toward new mate onto a child)

• Lack of effective parenting skills

• Inability to seek help from others

• Perception of the child as bad or evil

• History of drug or alcohol abuse

• Feeling of little or no control over life

• Low tolerance for frustration

• Poor impulse control

The term perpetrator applies to any member of a household who is violent toward another member (e.g., siblings, same-sex partners, extended family members). Both male and female perpetrators perceive themselves as having poor social skills. They describe their relationships with their partners as being the closest they have ever known, and they typically lack supportive relationships outside the relationship.

Men who abuse believe in male supremacy, being in charge, and being dominant. “Acting out” physically makes them feel more in control, more masculine, and more powerful. Parent-child interactions, peer group experiences, observations of the partner dyad, and the influence of the media (television, comics, video games, movies) all support the same message: Males can expect to be in a position of power in relationships and may use physical aggression to maintain that position.

Extreme pathological jealousy is characteristic of an abuser. Many refuse to allow their partners to work outside the home; others demand that their partners work in the same place as they do so that they can monitor activities and friendships. Many accompany their partners to and from all activities and forbid them to have personal friends or to participate in recreational activities outside the home. When this is not possible, a perpetrator may restrict mobility by monitoring the odometer and keeping stopwatches. Even after imposing such restrictions, abusers often accuse their partners of infidelity. Many perpetrators maintain their possessiveness by controlling the family finances so tightly that there is barely enough money for daily living.

Cycle of violence.

Walker (1979) describes a pattern of behavior that perpetrators of violence may use to control their partners. While there is little empirical evidence testing Walker’s theory, it is commonly cited to describe the dynamics of an abuser’s behavior. The tension-building stage is characterized by relatively minor incidents, such as pushing, shoving, and verbal abuse. During this time, the victim often ignores or accepts the abuse for fear that more severe abuse will follow. Abusers then rationalize that their abusive behavior is acceptable. As the tension escalates, both participants may try to reduce it. The abuser may try to reduce the tension with the use of alcohol or drugs, and the victim may try to reduce the tension by minimizing the importance of the incidents (“I should have had the house neater …. dinner ready”).

During the acute battering stage, the abuser releases the built-up tension by brutal beatings, which can result in serious injuries. After the abuse occurs, the abuser and victim enter a period of calm known as the honeymoon stage that is characterized by kindness and loving behaviors. The abuser, at least initially, feels remorseful and apologetic and may bring presents, make promises, and tell the victim how much she or he is loved and needed. The victim usually believes the promises, feels needed and loved, and drops any legal proceedings or plans to leave that may have been initiated during the acute battering stage.

Unfortunately, without intervention, the cycle will repeat itself. Over time, the periods of calmness and safety become briefer, and the periods of anger and fear are more intense. There are intervals of stability, but the violence increases over time. With each repeat of the pattern, the victim’s self-esteem becomes more and more eroded. The victim either believes the violence was deserved or accepts the blame for it. This can lead to feelings of depression, hopelessness, immobilization, and self-deprecation. Figure 28-1 illustrates the cycle of violence.