ABUSE AND NEGLECT INTRODUCTION Abuse is on the rise in this society.

Books, newspapers, and television inundate their readers and viewers with stories of mans inhumanity to man. Abuse affects all populations equally. It occurs among all races, religion, economic classes, ages and educational backgrounds. The phenomenon is cyclic in that many abusers were themselves victims of abuse as children. DEFINITIONS Abuse is defined as the maltreatment of one person by another. Battering is defined as a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner. Sexual assault is viewed as any type of sexual act in which an individual is threatened or coerced, or forced to submit against his or her will, Rape is a type of sexual assault. Rape is defined as the expression of power and dominance by means of sexual violence, most commonly by men over women, although men may also be rape victims. Neglect Physical neglect of the child includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runway to return home, and inadequate supervision. Emotional neglect refers to a chronic failure by the parent or caretaker to provide the child with the hope, love and support necessary for the development of a sound, healthy personality. PREDISPOSING FACTORS 1. BIOLOGICAL THEORIES` Neurophysiologic Influences: Various components of the neurological system can facilitate and inhibit aggressive impulses. Areas of brain that may be involved include the temporal lobe, the limbic system, and the amygdaloidal nucleus (Tardiff, 2003). Biochemical Influences: Studies show that various neurotransmitters- in particular norepinephrine, dopamine, and serotonin- may play a role in the facilitation and inhibition of aggressive impulses (Hollander, Berlin, & Stein, 2008). Genetic Influences: Genetic characteristic that was once thought to have some implication for aggressive behaviour was the genetic karyotype XYY. The XYY syndrome has been found to contribute to aggressive behaviour in a small percent of cases (Sadock & Sadock, 2007). Disorders of the brain: Brain tumors, particularly in the areas of limbic system and the temporal lobes; trauma to the brain, resulting in cerebral changes; and diseases, such as encephalitis and epilepsy, particularly temporal lobe epilepsy have all been implicated in the predisposition to aggressive and violent behaviour (Sadock & Sadock, 2007; Cummings & Mega, 2003; Tardiff, 2003).

2. PSYCHOLOGICAL THEORIES Psychodynamic theory: The psychodynamic theorists imply that unmet needs for satisfaction and security result in an underdeveloped ego and a weak superego. The immature ego cannot prevent dominant id behaviours from occurring, and the weak superego is unable to produce feelings of guilt. Learning theory: Children learn to behave by imitating their role models, which are usually their parents. Children may have an idealistic perception of their parents during the very early development stages but, as they mature, may begin to imitate the behaviour patterns of their teachers, friends, and others. Unfortunately, modeling can result in maladaptive as well as adaptive behaviour, particularly when children view heroes triumphing over villains by using violence. Individuals who were abused as

children or whose parents disciplined with physical punishment are more likely to behave in an abusive manner as adults (Tardiff, 2003).Unfortunately, modeling can result in maladaptive as well as adaptive behaviour, particularly when children view heroes triumphing over villains by using violence. 3. SOCIOCULTURAL THEORIES Societal Influences: Social scientists believe that aggressive behaviour is primarily a product of on es culture and social structure. Studies have shown that poverty and income are powerful predictors of homicide and violent crime. Societal influences contribute to violence when individuals realize that their needs and desires are not being met relative to other people (Tardiff, 2003).

SPECIAL POPULATION VULNERABLE FOR ABUSE 1. 2. 3. Intimate partner abuse Child abuse Elder abuse

INTIMATE PARTNER ABUSE Physical abuse between domestic partners may be known as spouse abuse, domestic or family violence, wife or husband battering, or intimate partner or relationship abuse. United States Bureau of Justice for 2004 (2007) reflected the following: Approximately 85 % of victims of intimate violence were women. Women ages 20 to 34 experienced highest per capita rate of intimate violence. Intimate partners committed 3% of nonfatal violence against men. Approximately 64 % of women and 54% of men reported the victimizations to police.

The most common reason for not reporting among women was fear of reprisal (violent response). Among men, the most common reason for not reporting was because it was a private or personal matter . Profile of Victim Women who are battered have low self esteem, commonly adhere to feminine sex-role stereotypes, and often accepts the blame for the batterers action. Feelings of guilt, anger, fear and shame are common. They may be isolated from family and support system. The battered women views her relationship as male dominant, and as the battering continues, her ability to see the options available to her and to make decisions concerning her life decreases. The phenomenon of learned helplessness may be applied to the womens progressing inability to act on her own behalf. Profile of the Victimizer Men who batter usually are characterized as persons with low self-esteem. Pathologically jealous, they present a dual personality, one to the partner and one to the rest of the world (Meskill & Conner, 2003). The typical abuser is very possessive and perceives his spouse as a possession. He becomes threatened when she shows any sign of independence or attempts to share herself and her time with others. The abusing man typically wages a continuous campaign of degradation against the female partner. He insults and humiliates her and everything she does at every opportunity. He strives to keep her isolated from others and totally dependent on him. He demands to know where she is at every moment, and when she tells him he challenges her honesty. He achieves power and control through intimidation. The Cycles of Battering:

Walker (1979) identified a cycle of predictable behaviours that are repeated over time. The behaviour can be divided into three distinct phases that vary in time and intensity both within the same relationship and among different couples. Phase I : The Tension-Building Phase. Phase II : The Acute Battering Incident. Phase III : Calm, Loving, Respite (Honeymoon) Phase.

PHASE I: THE TENSION-BUILDING PHASE During this phase, the women sense the mens tolerance for frustration is declining. He becomes angry with little provocation but, after lashing out at her, may be quick to apologize. Minor battering incident may occur during this phase, and in a desperate effort to avoid more serious confrontations, the women accepts the abuse as legitimately directed towards her. She denies her anger and rationalizes his behaviour. The minor battering incidents continue, and the tension mounts as the woman waits for the impending explosion. The abuser begins to fear that his partner will leave him. His jealousy and possessiveness increase, and he uses threats and brutality to keep her in his captivity. Battering incidents become more intense, after which the women become less and less psychologically capable of restoring equilibrium. She withdraws from him, which he misinterprets as rejection, further escalating his anger towards her. Phase I may last from a weeks to many months or even years. PHASE II: THE ACUTE BATTERING INCIDENT This is the most violent and shortest, usually lasting up to 24 hours. It most often begins with the batterer justifying his behaviour to himself. By the end of the incident, however, he cannot understand what has happened, only that in his rage he has lost control over his behaviour. During phase II, women feel their only option is to find a safe place to hide from the batterer. The beating is severe, and many women can describe the violence in great detail, almost as if dissociation from their bodies had occurred. The batterer generally minimizes the severity of the abuse. Help is usually sought only in the event of severe injury or if the women fears for her life or those of her children. PHASE III: CALM, LOVING, RESPITE (HONEYMOON) PHASE In this phase the batterer becomes extremely loving, kind, and contrite. He promises that the abuse will never recur and begs her forgiveness. He is afraid she will leave him and uses every bit of charm he can muster to ensure this does not happen. He believes he now can control the behaviour. During this phase the women relieves her original dream of ideal love and chooses to believe that this is what her partner is really like. This loving phase becomes the focus of the womens perception of the relationship. In an effort to steal a few precious moments of the phase III kind of loving, the battered women becomes a collaborator in her own abusive lifestyle. Victim and batterer become locked together in an intense, symbiotic relationship. Why does she stay? Women have been known to stay in a abusive relationship for many reasons, some of which include the following (Family Violence Law Center, 2003; National Coalition Against Domestic Violence, 2007). For the children For financial reason Fear of retaliation Lack of a support network Religious reasons Hopefulness CHILD ABUSE Erik Erickson (1963) stated, the worst sin is the mutilation of a childs spirit. Children are vulnerable and relatively powerless, and the effects of maltreatment are infinitely deep and long lasting. Child maltreatment typically includes physical or emotional injury, physical or emotional neglect, or sexual acts inflicted upon a child by a care giver

It is an act of robbing child basic rights. Those right include the rights to be and behave like a child; to be safe and protected from harm; and to be fed, clothed and nurtured so that the child can grow, develop and fulfill his or her unique potential. Physical Abuse Physical abuse of the child includes any physical injury as a result of punching, beating, kicking, biting, burning, shaking, throwing, stabbing, choking, or otherwise harming achild Signs of physical abuse Has unexplained burns, bites, bruises, broken bones, or black eyes. Has fading bruises or other marks noticeable after an absence from school. Seems frightened of the parents and protests or cries when it is time to go home. Shrinks at the approach of adults. Reports injury by a parent or another adult caregiver. Physical abuse may be suspected when the parent or other adult care giver: Offers conflicting, unconvincing, or no explanation for childs injury. Describes the child as evil, or in some other very negative way. Uses harsh physical discipline with the child. Has a history of abuse as a child. Emotional Abuse Emotional abuse involves a pattern of behaviour on the part of the parent or care taker that results in serious impairment of the childs social emotional or intellectual functioning. Examples of emotional injury include belittling or rejecting the child, ignoring the child, blaming the child for things over which he or she has no control, isolating the child from normal social experiences and using harsh and inconsistent discipline Indicators of emotional abuse: Shows extremes in behaviour, such as overly complaint or demanding behaviour, extreme passivity, or aggression. Is delayed in physical or emotional development. Has attempted suicide. Reports a lack of attachment to the parents. Emotional abuse suspected when the parent or other adult care giver: Constantly blames, belittle the child. Is unconcerned about the child and refuses to consider offers of help for the childs problems. Overtly rejects the child. Physiological and emotional neglect Indicators of neglect Is frequently absent from school. Begs or steals food or money. Lacks needed medical or dental care, immunizations or glasses. Is consistently dirty and has severe body odor. Lack sufficient clothing for the weather. Abuses alcohol or other drugs. States that there is no one at home to provide care. Possibility of neglect when parent or other adult caregiver: Appears to be indifferent to the child. Seems apathetic or depressed. Behaves irrationally or in a bizarre manner. Is abusing alcohol or other drugs. Sexual abuse of the child Employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexual explicit conduct or any stimulation of such conduct for the purpose of producing any visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children.

Sexual exploitation of a child is when the child in induced or coerced into engaging in sexually explicit conduct for the purpose of promoting any performance, and child sexual abuse, in which a child is being used for sexual pleasure of an adult or any other person. Indicators of sexual abuse Has difficulty walking or sitting Suddenly refuses to change for gym or to participate in physical activities Reports nightmares or bedwetting Experiences a sudden change in appetite Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behaviour Becomes pregnant or contracts a venereal disease, particularly if younger than age 14 Runs away Reports sexual abuse by a parent or another adult caregiver. Sexual abuse may be considered possible when the parent or other adult caregiver In unduly protective of the child or severely limits the childs contact with other children, especially of the opposite sex. Is secretive and isolated. Is jealous or controlling with family members. Characteristics of a child abuser Experiencing a stressful life situation. Having few, if any support systems; commonly isolated from others. Lacking understanding of child development or care needs. Lacking adaptive coping strategies; angers easily; has difficulty trusting others. Expecting the child to be perfect; may exaggerate any mild difference the child manifests from the usual. Rape Rape is a broad spectrum of experiences ranging from the surprise attack by a stranger to insistence on sexual intercourse by an acquaintance or spouse. Rape is an act of aggression, not one of passion. Date rape is a term applied to situations in which the rapist is known to the victim (Sadock &Sadock, 2003). An increasing number of colleges and universities are establishing programs for rape prevention and counseling for victims of rape. Marital rape, which has been recognized only in recent years as a legal category, is the case in which a spouse may be held liable for sexual abuse directed at a marital partner against that persons will. Statutory rape is defined as unlawful intercourse between a man older than 16 years of age and a women under the age of consent (Sadock &Sadock, 2003). The age of consent varies from state to state, ranging from age 14 to 21. A man who has intercourse with women under the age of consent can be arrested for statutory rape, although the interaction may have occurred between consenting individuals. The charges, when they occur, usually are brought by the young womens parent. Manifestations : Contusions and abrasions about various parts of the body. Headaches, fatigues, sleep pattern disturbances. Stomach pains , nausea and vomiting. Vaginal discharge and itching, burning upon urination, rectal bleeding and pain. Rage, humiliation, embarrassment, desire for revenge, and self-blame. Fear of physical violence and death. ELDER ABUSE Abuse of elderly individuals, which at times has been referred to in the media as granny -bashing, is a serious form of family violence. Sadock and Sadock (2003) estimate that 10 percent of individuals over age 65 are the victims of abuse or neglect. The abuser is often a relative who lives with the elderly person and may be the assigned caregiver. Typical caregivers who are likely to be abusers of the elderly were described by Murray and Zentner (2001) as being under economic stress, substance abusers, themselves the victims of previous family violence, and exhausted and frustrated by the caregiver role.

Abuse of elderly individuals may be psychological, physical, or financial. Neglect may be intentional or unintentional. Psychological abuse includes yelling, insulting, harsh commands, threats, silence, and social isolation. Physical abuse is described as striking, shoving, beating, or restraint. Financial abuse refers to misuse or theft of finances, property, or material possessions. Neglect implies failure to fulfill the physical needs of an individual who cannot do so independently. Unintentional neglect is inadvertent, whereas intentional neglect is deliberate. In addition, elderly individuals may be the victims of sexual abuse, which is sexual intimacy between two persons that occurs without the consent of one of the persons involved. Another type of abuse, which has been called granny-dumping by the media, involves abandoning elderly individuals at emergency departments, nursing homes, or other facilitiesliterally leaving them in the hands of others when the strain of caregiving becomes intolerable. The elderly person may be unwilling to disclose information because of fear of retaliation, embarrassment about the existence of abuse in the family, protectiveness toward a family member, or unwillingness to institute legal action. Adding to this unwillingness to report is the fact that infirm elders are often isolated. Factors that Contribute to Abuse Longer Life The 65-and-older age group has become the fastest growing segment of the population. Within this segment, the number of elderly older than age 75 has increased most rapidly. This trend is expected to continue well into the 21st century. The 75 and older age group is the one most likely to be physically or mentally impaired, requiring assistance and care from family members. This group also is the most vulnerable to abuse from caregivers. Dependency Dependency appears to be the most common precondition in domestic abuse. Changes associated with normal aging or induced by chronic illness often result in loss of self-sufficiency in the elderly person, requiring that they become dependent on another for assistance with daily functioning. Long life may also consume finances to the point that the elderly individual becomes financially dependent on another as well. This dependence increases the elderly persons vulnerability to abuse. Stress The stress inherent in the caregiver role is a factor in most abuse cases. Some clinicians believe that elder abuse results from individual or family psychopathology. Others suggest that even psychologically healthy family members can become abusive as the result of the exhaustion and acute stress caused by overwhelming caregiving responsibilities. This is compounded in an age group that has been dubbed the sandwich generationthose individuals who elected to delay childbearing so that they are now at a point in their lives when they are sandwiched between providing care for their children and providing care for their aging parents. Learned Violence Children who have been abused or witnessed abusive and violent parents are more likely to evolve into abusive adults. Stanley, Blair, and Beare (2005) state: Violence is a learned behavior that is passed down from generation to generation in some families because violence has been modeled as an acceptable coping behavior, with no substantial penalties for the behavior. This model suggests that a child who grows up in a violent family will also become violent. Some believe that elder mistreatment may be related to retribution on the part of an adult offspring who was abused as a child. Identifying Elder Abuse Indicators of psychological abuse include a broad range of behaviors such as the symptoms associated with depression, withdrawal, anxiety, sleep disorders, and increased confusion or agitation. Indicators of physical abuse may include bruises, welts, lacerations, burns, punctures, evidence of hair pulling, and skeletal dislocations and fractures. Neglect may be manifested as consistent hunger, poor hygiene, inappropriate dress, consistent lack of supervision, consistent fatigue or listlessness, unattended physical problems or medical needs, or abandonment Sexual abuse may be suspected when the elderly person is presented with pain or itching in the genital area, bruising or bleeding in external genitalia, vaginal, or anal areas, or unexplained sexually transmitted disease.

Financial abuse may be occurring when there is an obvious disparity between assets and satisfactory living conditions or when the elderly person complains of a sudden lack of sufficient funds for daily living expenses.

SUICIDE Although persons older than age 65 comprise only 12 percent of the population, they represent a disproportionately high percentage of individuals who commit suicide. Of all suicides, 20 percent are committed by this age group, and suicide is the 15th leading cause of death among the elderly (Charbonneau, 2003). Predisposing factors include loneliness, financial problems, physical illness, loss, and depression (Sadock & Sadock, 2003). Several studies have found that many older adults who die by suicide up to 75 percenthave visited a primary care physician within a month of their suicide. These findings point to the urgency of enhancing both the detection and the adequate treatment of depression as a means of reducing suicide risk among older persons. In assessing suicide intention, Stanley, Blair, and Beare (2005) suggest that, using concern and compassion, direct questions such as the following should be asked: Have you thought life is not worth living? Have you considered harming yourself? Do you have a plan for hurting yourself? Have you ever acted on that plan? Have you ever attempted suicide? Components of intervention with a suicidal elderly person should include demonstrations of genuine concern, interest, and caring; indications of empathy for their fears and concerns; and help in identifying, clarifying, and formulating a plan of action to deal with the unresolved is sue. If the elderly persons be havior seems particularly lethal, additional family or staff coverage and contact should be arranged to prevent isolation. TREATMENT MODALITY Crisis Intervention The goal of crisis intervention is to help victims return to their previous lifestyle as quickly as possible. The client should be involved in the intervention from the beginning. This promotes a sense of competency, control, and decision-making. Because an over whelming sense of powerlessness accompanies the rape experience, active involvement by the victim is both a validation of personal worth and the beginning of the recovery process. Crisis intervention is time limited usually 6 to 8 weeks. If problems resurface beyond this time, the victim is referred for assistance from other agencies (e.g., long-term psychotherapy from a psychiatrist or mental health clinic). During the crisis period, attention is given to coping strategies for dealing with the symptoms common to the post trauma client. Initially the individual undergoes a period of disorganization during which there is difficulty making decisions, extreme or irrational fears, and general mistrust. Observable manifestations may range from stark hysteria, to expression of anger and rage, to silence and withdrawal. Guilt and feelings of responsibility for the rape, as well as numerous physical manifestations, are common. The crisis counselor will attempt to help the victim draw upon previous successful coping strategies to regain control over his or her life. The Safe House or Shelter Safe houses or shelters for women are to be assured of protection for them and their children. These shelters provide a variety of services, and the women receive emotional support from staff and each other. Most shelters provide individual and group counseling; help with bureaucratic institutions such as the police, legal representation, and social services; child care and childrens programming; and aid for the woman in mak ing future plans, such as employment counseling and linkages with housing authorities. The shelters are usually run by a combination of professional and volunteer staff, including nurses, psychologists, lawyers, and others. Women who themselves have been previously abused are often among the volunteer staff members.

Group work is an important part of the service of shelters. Women in residence range from those in the immediate crisis phase to those who have progressed through a variety of phases of the grief process. Those newer members can learn a great deal from the women who have successfully resolved similar problems. Length of stay varies a great deal from individual to individual, depending on a number of factors, such as outside support network, financial situation, and personal resources. The shelter provides a haven of physical safety for the battered woman and promotes expression of the intense emotions she may be experiencing regarding her situation. A woman often exhibits depression, extreme fear, or even violent expressions of anger and rage. In the shelter, she learns that these feelings are normal and that others have also experienced these same emotions in similar situations. She is allowed to grieve for what has been lost and for what was expected but not achieved. Help is provided in overcoming the tremendous guilt associated with self-blame. This is a difficult step for someone who has accepted responsibility for anothers behavior over a long period. Family Therapy The focus of therapy with families who use violence is to help them develop democratic ways of solving problems. Studies show that the more a family uses the democratic means of conflict resolution, the less likely they are to engage in physical violence. Families need to learn to deal with problems in ways that can produce mutual benefits for all concerned, rather than engaging in power struggles among family members. Parents also need to learn more effective methods of disciplining children, aside from physical punishment. Methods that emphasize the importance of positive reinforcement for acceptable behavior can be very effective. Family members must be committed to consistent use of this behavior modification technique for it to be successful. Teaching parents about expectations for various developmental levels may alleviate some of the stress that accompanies these changes. Knowing what to expect from individuals at various stages of development may provide needed anticipatory guidance to deal with the crises commonly associated with these stages. Therapy sessions with all family members together may focus on problems with family communication. Members are encouraged to express honest feelings in a manner that is nonthreatening to other family members. Active listening, assertiveness techniques, and respecting the rights of others are taught and encouraged. Barriers to effective communication are identified and resolved.