Families

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Families social issues and abuse

• Prof. Rosanda Mulic, MD, PhD

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Family Issues Marital conflict, Divorce, Abuse,
Neglect

• To competently serve families, medical students
  must understand the theories and issues
  surrounding family violence, adult victims of
  family violence, adult survivors of child abuse,
  child witnesses of domestic violence, adolescent
  victims of dating violence, elderly victims, and
  perpetrators of abuse.

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Family Systems model

• Primary assumptions- Reciprocal Individuals
  shape their environment and are shaped by the
  environment as well
• Dynamic constant interactions among individuals
  and their environments
• Hierarchical structure defined by boundaries and
  subsystems

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Marital ConflictTypes and Child Outcomes

• Physical (Domestic Violence)
• - Most linked with externalizing problems in
  children
• - Traumatic symptoms
• Verbal Aggression
• Both externalizing and internalizing problems
• Withdrawal (Stonewalling)
• - Most linked with depression, anxiety and
  social withdrawal in children
• Mutually respectful, emotionally regulated
  conflict resolution
• Well adjusted children with social,
  problem-solving skills

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Other Outcomes

• Childhood
• - Lower academic achievement
• - Poorer self-concept
• - Poorer social competence
• Adulthood
• Lower SES (socio-economic status)
• Poorer self-concept
• Increased marital problems
• Greater likelihood of divorce

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Direct and Indirect Effects

• Direct
• Repeated exposure to conflict undermines
  childrens capacity for regulating their
  emotional and behavioral functioning

• Indirect
• Spillover hypothesis
• Impact of parenting leading to changes in
  emotional availability (rejection, hostility) and
  control (lax monitoring, inconsistent or harsh
  discipline)

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Divorce

• Childrens post-divorce adjustment affected by
  magnitude and force by divorce stressors
• Interpersonal and intrapersonal resources
• Interaction between divorce stressors and
  resources

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Divorce Models

• Crisis Acute stress with transition
• Gradual adjustment
• Protective factors/Stress buffers
• - Adults education, employment, social support
• - Children active coping skills, social
  support, access to therapeutic intervention
• - Parent-child Maternal acceptance
• Consistency of Discipline

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Divorce Models

• Chronic Strain
• Persistent long-term problems
• Risk factors - disruptions in parent-child
  relations
• (inept/neglectful parenting)
• - Continuing discord among spouses
• Loss of emotional support
• Economic hardship
• Negative life events (moving, changing schools)

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Coping with Divorce

• Component of effective treatmens
• Improve mother-child relationship quality
• Praise
• Reflective listening
• Positive activity scheduling
• Improve effective discipline
• Structure and consistent
• Logical consequences
• Decrease pysical punishment
• Co-parenting increase fathers access to child
• Reduce interparental conflict

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Co-parenting

• People who separate but continue to work
  cooperatively as parents
• Respectful (no criticism)
• Resolve conflicts privately
• Discuss major issues together an arrive at mutual
  understanding before speaking with children
• Dont make child confidant
• Dont make child messenger

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Co-parenting

• Points to consider
• - Be clear that divorce is final and NOT childs
  fault
• Remember to problem solve
• Education
• Visitation schedule
• Finances
• Medical needs
• Discipline Holidays/special events
• NOT RECOMENDED FOR ALL FAMILIES

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Coping with Divorce

• Componets of Effective Treatments
• Coping skills training
• Emotion labelling and expression
• Positive cognitive reframing to reduce negative
  thougts about divorce stressors
• Effective communication I messages
• Identify ways to find social support

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• Child Abuse and Neglect

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Child Abuse and Neglect

• Sexual Abuse
• Any penetration no matter how slight by penis or
  any object
• Any sexual contact of any genital area by
  persons genitals, mouth, tongue, hand etc
• Intentional masturbation
• Sexual exploitation (engaging in sexual acts or
  prostitution).

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Sexual Abuse

• Drawing of a sexually abused girl aged five

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Sexual Abuse

• Provided courtesy of the staff the Children's
  Hospital, Klajic street Zagreb
• See the extension of the anus and intertrigo
  caused by neglect

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Mental Injury/Emotional abuse

• Injury in intellectual or psychological capacity
  as evidenced by a discernable and substantial
  impairment in persons ability to function within
  the normal range of performance
• Physical Harm
• - Acts including punching, beating, kicking,
  biting, burning and shaking

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Physical Harm

• Provided courtesy of the staff the Children's
  Hospital, Klajic street Zagreb

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Physical Harm
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Physical Harm
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Correlates of Child Abuse

• Parents have little exposure to positive parental
  models and support
• Greater degree of stress in family environment
• Information processing disturbances may cause
  parents to misperceive childs behavior or intent
• Lack of awareness or developmentally appropriate
  expectations
• Conflict and marital violence

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Sequelae of Child Abuse

• Emotional
• Anxiety and depression
• Low self esteem
• Increased anger/conflict
• Guilt and shame

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Sequelae of Child Abuse

• Social
• Withdrawn
• Inappropriate sexual behavior
• Vulnerability for re-victimization

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Sequelae of Child Abuse

• Behavioral
• Runaway behavior
• Selfdestructive behavior
• Substance abuse

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Sequelae of Child Abuse

• Physical
• Medical problems
• Somatic complains
• Injuries

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Mediating Factors of Child Abuse

• Age of childYounger children are more vulnerable
  and have not developed good coping skills,
  however, older children are more aware of social
  stigma with abuse
• Psychological condition of victim Child with
  prior emotional problems or an unstable home
  environment may experience more pronounced
  problems
• Not being believed or supported especialy from
  others they trust

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Mediating Factors of Child Abuse

• Stranger vs. known person
• more damaging effects if assaulted by a trusted
  person
• Sexual knowledge or experience
• child with no prior sexual experience may be more
  vulnerable
• Type of assault
• amount of bodily harm or penetration does child
  believe body has been damaged?
• Repetaed assaults
• more harm of repeatedly being abused

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Mediating Factors of Child Abuse

• Therapy
• More likely to recover if they have individual
  therapy, and when they are ready, support group

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Child Neglect

• Physical Inadeqaute attention to clothing, food,
  and health-care needs
• Emotional Inadeqaute attention to childs
  emotional and developmental needs
• Educational failure to enroll a child in school
  in violation of state law, permitting chronic
  truancy, or refusing to allow needed attention to
  a diagnosed educational problem

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Correlates of Child Neglect

• Poverty (most significant)
• Unemployment
• Housing instability
• Single parenthood
• High risk neighborhoods
• Household crowding

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Correlates of Child Neglect

• Family interaction style and stability
• Lack of affect/apathetic
• Impulsive parents with poor planing and
  organization
• Lack of knowledge about childrearing
• Social isolation
• Conflict
• Infrequent and critical parent-child interaction
• Children with medical or developmental problems

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Sequelae of Child Neglect

• Emotional
• insecure attachment,
• Low self esteem
• Increased anger/conflict
• Social
• Passive
• Withdrawn
• Aggressive with peers

• Cognitive
• Impaired development due to lack of stimulation
• Poor academic success
• Physical
• Medical problems
• Malnutrition

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Resilience and Adaptation

• Positive relationship with at least one important
  and consistent person who provides support and
  protection
• Positive self-esteem and sense of self

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Prevention and treatment

• Early prevention is key!
• However, difficult if parents cannot acknowledge
  maltreatment
• Parent and family focused interventions
• Training in child rearing
• Stress management
• Address anger patterns/disorder beliefs
• Address parental expectations
• Household management skills

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Prevention and treatment

• Interventions for children
• Adress childrens need for safety
• Emphasize emotional expression
• Adress cognitive distortions regarding World as
  a scary place

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Other Family Issues

• Siblings
• Stepfamilies
• Single parent families
• Maternal employment
• Gay/lesbian parents
• Adoption?