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Families – social issues and abuse Prof. Rosanda Mulić, MD, PhD 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. 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 Marital Conflict: Types 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 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 Direct and Indirect Effects Direct Indirect Repeated exposure to Spillover hypothesis: conflict undermines Impact of parenting children’s capacity for leading to changes in regulating their emotional availability emotional and behavioral (rejection, hostility) and functioning control (lax monitoring, inconsistent or harsh discipline) Divorce Children’s post-divorce adjustment affected by magnitude and force by divorce stressors Interpersonal and intrapersonal resources Interaction between divorce stressors and resources 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 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) 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 father’s access to child - Reduce interparental conflict 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 - Don’t make child “confidant” - Don’t make child “messenger” Co-parenting Points to consider: - Be clear that divorce is final and NOT child’s fault - Remember to problem solve: - Education - Visitation schedule - Finances - Medical needs - Discipline Holidays/special events - NOT RECOMENDED FOR ALL FAMILIES 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 Child Abuse and Neglect 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 person’s genitals, mouth, tongue, hand etc… Intentional masturbation Sexual exploitation (engaging in sexual acts or prostitution). Sexual Abuse Drawing of a sexually abused girl aged five 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 Mental Injury/Emotional abuse Injury in intellectual or psychological capacity as evidenced by a discernable and substantial impairment in person’s ability to function within the normal range of performance Physical Harm - Acts including punching, beating, kicking, biting, burning and shaking Physical Harm Provided courtesy of the staff the Children's Hospital, Klajic street Zagreb Physical Harm Physical Harm 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 child’s behavior or intent Lack of awareness or developmentally appropriate expectations Conflict and marital violence Sequelae of Child Abuse Emotional: - Anxiety and depression - Low self esteem - Increased anger/conflict - Guilt and shame Sequelae of Child Abuse Social: - Withdrawn - Inappropriate sexual behavior - Vulnerability for re-victimization Sequelae of Child Abuse Behavioral - Runaway behavior - Selfdestructive behavior - Substance abuse Sequelae of Child Abuse Physical: - Medical problems - Somatic complains - Injuries Mediating Factors of Child Abuse Age of child:Younger 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 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 Mediating Factors of Child Abuse Therapy: More likely to recover if they have individual therapy, and when they are ready, support group Child Neglect Physical: Inadeqaute attention to clothing, food, and health-care needs; Emotional: Inadeqaute attention to child’s 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 Correlates of Child Neglect Poverty (most significant) Unemployment Housing instability Single parenthood High risk neighborhoods Household crowding 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 Sequelae of Child Neglect Emotional: Cognitive: insecure attachment, Impaired Low self esteem; development due to Increased lack of stimulation; anger/conflict Poor academic success Social: Passive Physical: Withdrawn Medical problems Aggressive with Malnutrition peers 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 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 Prevention and treatment Interventions for children: Adress children’s need for safety Emphasize emotional expression Adress cognitive distortions regarding “World as a scary place” Other Family Issues Siblings Stepfamilies Single parent families Maternal employment Gay/lesbian parents Adoption?
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