1. Families in Crisis: violence and abuse
Family crisis
Types
Developmental
Situational
Multiple
Family violence against children
Child abuse
Child neglect
Emotional abuse
Physical abuse
Sexual abuse
Reporting abuse
Role of the community health nurse in caring for families in crisis

2. Introduction:
A family crisis is a stressful and disruptive event (or series of events) that comes with or without warning and disturbs the equilibrium of the family.
A family crisis can also result when usual problem-solving methods fail. All families experience periods of crisis.
A toddler is diagnosed with a serious illness; a teenager discovers she is pregnant; a father and sole breadwinner in a family loses his job; a mother’s social drinking becomes habitual after her children go off to college.

3. Cont…
You probably can identify one or more periods of crisis that you and your family members have experienced. If so, how directly were you affected? How did the crisis resolve? As a result of the crisis, were there any permanent changes in your family’s dynamics or individual behaviors?
People respond to crises differently. Some approach them as a challenge, an event to be adapt with; others are overwhelmed and feel defeated or give up. Some seek help if needed and come through the experience unscathed or as survivors, perhaps even stronger than before.

4. DYNAMICS AND CHARACTERISTICS OF A CRISIS
Researchers have studied the nature of crises and have developed a body of knowledge called crisis theory:
When some internal or external force disrupts our system’s balance and alters its functioning, loss of equilibrium occurs. We then attempt to restore equilibrium by using whatever resources are available to us.
Coping refers to those actions and ways of thinking that assist people in dealing with and surviving difficult situations. If we cannot readily cope with a stressful event

5. Cont…
Crises are precipitated by specific identifiable events that become too much for the usual problem-solving skills of those involved.
Often a crisis is not an event per se, but rather a person’s perception of the event. Each person reacts in his or her own individual way.
Crises are resolved, either positively or negatively, within a brief period, usually 4 to 8 weeks

6. Types of family crises

7. 1. Developmental Crises
Developmental crises are periods of disruption that occur at transition points during normal growth and development.
When developmental crises occur, people feel threatened by the demands placed on them and have difficulty making the changes necessary to fit the new stage of development.

8. Cont… Most family developmental crises have a gradual onset
Developmental crises arise from both physical and social changes
Each stage is unique and different from the others
Transitions from one stage to the next require changes in roles and behaviour.
Ex. a child born to a newly married couple demands a changes in roles and responsibilities , this situation increased the financial burdens, feeling of boredom and loss of freedom, this may result on huge psychological stress and lead to a family crises.

9. 2. Situational Crises
A situational crisis: is a stressful, disruptive, event arising from external circumstances that occurs suddenly, often without warning, to a person, group, aggregate, or community.
The external changes may require behavioral changes beyond the abilities of the family members to cope with it

10. Cont…
The changes are unexpected and unplanned as it happened because of the people presence in a time and space (e.g. a baby grabs her mother’s hot cup of tea and burns her chest; an older adult falls and fractures a hip).
CHNs see an almost infinite variety of situational crises. In each situation, people feel overwhelmed and need help to cope. Skilled intervention can make the difference between a healthy and an unhealthy outcome

11. 3. Multiple Crises
Different kinds of crises can overlap in actual experience, compounding the stress felt by the persons involved
Example: With older adults, the developmental crisis of retirement may be compounded by the situational crisis of a fire that destroys the family home.
The transition a child faces entering school may occur at the same time the family moves to a new neighborhood and a new infant joins the family.

12. History of Family Violence
The terms domestic violence, family violence, and interpersonal violence refer to morbidity and mortality attributable to violence within the home setting, involving action by a family member or intimate partner.
They involve “a systematic pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks and economic coercion, that adults or adolescents use against their intimate partners”
This type of violence is becoming more of a global burden.

13. Global & nationally statistics
Globally between 16% and 52% of women experience domestic violence
In Jordan more than 5000 case yearly reported domestic approach.
3200 child received at youth reform centers produce from domestic abuse.
2000 cases yearly received at family protection centers.
New law regarding family protection start to apply since 2006
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14. Cont…
وتظهر دراسة شاملة نفذتها "اليونيسيف"، بالتعاون مع المجلس الوطني لشؤون الأسرة حول العنف ضد الأطفال في الأردن، في العام 2007، ارتفاعا واضحا في حالات العنف الجسدي والنفسي ضد الأطفال في المدارس والمنازل والمجتمع المحلي.
وتكشف عن رضى وقبول من الأهالي وأولياء الأمور بعقاب أبنائهم، كوسيلة مناسبة "للتأديب ولتعديل السلوك الخاطئ". وبيّنت أن أكثر من 70 % من الأطفال يتعرضون للإساءة اللفظية من قبل أولياء الأمور والمعلمين والإداريين في المدارس.
وتبيّن الدراسة التي شملت 5489 طفلاً من مختلف مناطق المملكة، أن أكبر مصدر لعقاب الأطفال في البيت هم الوالدان وأولياء الأمور، يليهما الإخوة وأقارب الطفل، ثم الأطفال الآخرون.
وتقول إن أكثر من ثلثي الأطفال تعرضوا للإساءة اللفظية، فيما تعرض ثلث الأطفال إلى إساءات غير لفظية من الوالدين أو أولياء الأمور والإخوة.
ولوحظ أن نسب الإناث اللواتي مورست ضدهن الإساءة اللفظية وغير اللفظية كانت أعلى قليلاً من الأطفال الذكور، خصوصاً عندما كان مصدر الإساءة الوالدين وأولياء الأمور والإخوة. أما الأقارب، فكانت ممارستهم للإساءة اللفظية وغير اللفظية موجهة للأطفال الذكور أكثر من الإناث.

15. Myths and Truths About Family Violence
Strongly held myths by members of society, including community health nurses and other health care providers, may interfere with getting families in crisis the help they need. (Table 25–1 page 562) displays some common myths and truths about family violence.

16. Main Categories of Family Violence
Violence against children
Child neglect, physical abuse, sexual abuse, emotional abuse
Shaken baby syndrome, Munchausen syndrome by proxy, Internet crimes against children, child abduction, crimes against children by babysitters
Partner/spousal violence
Mistreatment of elders
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17. FAMILY VIOLENCE AGAINST CHILDREN
This emerging new morbidity is of a psychosocial nature, is associated with behavioral problems, and is much more difficult to prevent than diseases known for centuries.
Child abuse is the maltreatment of children. It may include any of the following: physical, emotional, medical, or educational neglect; physical punishment or battering; and emotional or sexual maltreatment and exploitation. Types can occur alone or in combination.

19. Child Neglect
Neglect occurs when the physical, emotional, or educational resources necessary for healthy growth and development are withheld or unavailable.
Neglect could be obvious e.g a child cloths is inappropriate for the weather or a child playing outside unattended.
Neglect is not always so obvious. Parents may refuse to buy eyeglasses for a child who needs them (medical neglect). An 8-year-old may get to school only 3 days a week, usually without breakfast and with no lunch money or packed lunch (educational neglect).

20. Signs and Symptoms of Neglect
• The child lacks adequate medical or dental care.
• The child is often sleepy or hungry.
• The child is often dirty, demonstrates poor personal hygiene.
• There is evidence of poor or inadequate supervision for the child’s age.
• The conditions in the home are unsafe or unsanitary.
• The child appears to be malnourished.
• The child is depressed, withdrawn, or apathetic.

21. Physical Abuse
Physical abuse is intentional harm to a child by another person that results in pain, physical injury, or death. The abuse may include striking, biting, poking burning, shaking, or throwing the child
Corporal punishment, which involves violence against a child as a form of discipline.

22. Cont…
Battered child syndrome refers to the collection of injuries that are sustained by a child as a result of repeated mistreatment or beatings

23. Signs and Symptoms of Physical Abuse
Types of Injuries
Injuries include bruises, burns, bite marks, abrasions, lacerations, head injuries, internal injuries, and fractures.
Behavioural Indicators of Physical Abuse
• The child is frightened of parents/caretakers or, at the other extreme, is overprotective of parent or caretakers.
• The child is excessively passive, overly compliant, apathetic, withdrawn or fearful or, at the other extreme, excessively aggressive, destructive, or physically violent.

24. Cont… • The child and/or parent or caretaker attempts to hide
injuries, Child wears excessive layers of clothing, especially in hot weather
Child is frequently absent from school or misses physical education classes if changing into gym clothes is required
Child has difficulty sitting or walking
• The child is frightened of going home
• The child is clingy and forms indiscriminate (haphazard) attachments.
• The child is apprehensive (anxious) when other children cry.

25. Sexual Abuse
Sexual abuse of children includes acts of sexual assault or sexual exploitation of a minor and may consist of a single incident or many acts over a long period.
Sexual assault includes rape, gang rape, incest, sodomy, lewd or lascivious acts with a child younger than 14 years of age.

26. Cont…
Sexual exploitation of children includes conduct or activities related to pornography that depict minors in sexually explicit situations and promotion of prostitution by minors.
Incest is sexual abuse among family members who are related by blood (eg, parents, grandparents, older siblings, aunts and uncles). it constitutes the most hidden form of child abuse.
Intrafamilial sexual abuse refers to sexual activity involving family members who are not related by blood (eg, step-parent boyfriends).

27. Emotional Abuse
Emotional abuse of children involves psychological mistreatment or neglect, such as when parents do not provide the normal experiences that produce feelings of being loved, wanted, secure, and worthy.
This too can take several different forms. It may involve verbal abuse, such as calling the child names, belittling, or threatening. A mother may shout at the child.

28. Specific Abusive Situations
Shaken baby syndrome is the intentional abusive action of violently shaking an infant or toddler, usually one younger than 18 months of age.
Munchausen syndrome is a psychological disorder in which a client fabricates the symptoms of a disease in order to undergo medical tests, hospitalization, or even medical or surgical treatment.
Munchausen syndrome by proxy, a parent or caretaker suffering from Munchausen syndrome attempts to bring medical attention to himself or herself by injuring or inducing illness in his or her children.

29. Reporting Abuse
The following steps represent one state’s guidelines for reporting suspected child abuse:
All mandated reporters must report known or suspected abuse.
2. Immediately, or as soon as reasonably possible, a local
child protective agency (police department after normal
working hours) must be contacted and given a verbal report.
3. Within 2 working days, a written report must be completed by the mandated reporter and filed

31. Assessment, Nursing Diagnosis
Initially, the nurse must assess the nature of the crisis and the clients’ response to it. How severe is the problem, and what risks do the clients face? Are other people also at risk?
First, the nurse concentrates on the immediate problem during the assessment. Why have clients asked for help right now? How do they define the problem? What precipitated the crisis? When did it occur? Was it a sudden accidental or situational event, or a slower developmental one?

32. Cont…
Next, the nurse focuses on the clients’ perceptions of the event. What does the crisis mean to them, and how do they think it will affect their future? Are they viewing the situation realistically? When a crisis occurs to a family or group, some members see the situation differently from others.
Determine what persons are available for support. Consider family, friends, clergy, other professionals, community members, and agencies. With whom are the clients close, and whom do they trust?

33. Cont…
Finally, the nurse assesses the clients’ coping abilities. Have they had similar kinds of experiences in the past? What techniques have they previously used to relieve tension and anxiety? Which techniques have they tried in this situation, and if they did not work, why not?
The nurse gathers all data and mentally begins to form nursing diagnoses.

34. Planning Therapeutic Intervention
Nurses should try to determine what factors are affecting clients before making intervention plans (e.g. clients’ perceptions of the event, situational supports, human resources, and clients’ coping skills)
The nurse should also considers the clients’ general
health status, age, past experiences with similar types of situations, socio-cultural and religious influences, and the actual assets and liabilities of the situation.
The plan is based on the kind of crisis (situational or developmental, acute or chronically recurring)
Using the problem-solving process, nurse and clients develop a plan

35. Implementation: Demonstrate acceptance of clients.
Help clients confront crisis. Clients need to face and discuss the situation.
Help clients find facts.
4. Help clients express feelings openly
5. Do not offer false reassurance
6. Discourage clients from blaming others
7. Help clients seek out coping mechanisms
8. Encourage clients to accept help. Denial in the early phases of crisis cuts off help
9. Promote development of new positive relationships

36. Evaluation: CHN should evaluate the outcome of the intervention
Are the clients using effective coping skills and exhibiting appropriate behavior? Are adequate resources and support persons available? Is the diagnosed problem solved, and have the desired results been accomplished?
To stabilize the change, identify and reinforce all the positive coping mechanisms and behaviors

37. Thank You