Social

							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?