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?