Tuesday, December 4, 2007

Preventing Child Abuse and Neglect

Child abuse and neglect (CAN) is a serious problem that results in devastating and long lasting damage to the individual affected, and to the community at large. Abuse and neglect in childhood can destroy self-esteem, self-concept, relationships, and the ability to trust (Valente, 2005).

Because nurses are on the frontline of assessment, they must be trained to recognize child abuse and neglect, and they must be trained in the proper response to positive screening results. Nurses must also be educated in methods of support for affected victims, and in ways to prevent abuse and neglect.
Children who are abused and neglected often come to believe that they do not deserve loving treatment. Abuse teaches those who suffer from it that others can not be trusted. Neglect and abuse of children is far from rare: The American Humane Association (2003) cites statistics that indicate that 17% of college students experienced abuse before the age of 18. The effects of abuse and neglect persist throughout the lifetime of the affected child. Society is affected as well, because those whose belief in themselves is shattered may turn to criminal enterprises, are more likely to engage in substance abuse, and are more likely to be sexually promiscuous (Overstolz, 2001).
Nurses are well trained to recognize the indicators of physical disease. Screening for problems with hearing and vision is a common nurse's role in primary schools. Because nurses routinely conduct screenings and assessments, they are ideally placed to also screen for the indicators of CAN. However, even nurses who have been practicing for many years may often believe that they have had little or no experience with abused or neglected children. To remedy this problem, programs are being developed to educate nurses in identification of the at-risk or victimized child (Young, Jackson, 2007). Studies have shown that nurses are interested in learning to screen for CAN, and that they feel confident in their ability to effectively do so (Waibel-Duncan, 2006). Once the nurse has identified a child who is at risk for or experiencing CAN, he or she needs to respond properly. Education of nurses in the identification of CAN must therefore include training in the appropriate response to positive screens. This response may include notification of legal authorities or supportive interventions for the family, depending on the severity of the indicators observed and the parties involved. Just as protocols are developed to achieve high standards of physical care, so too should nurses act to develop protocols for response to danger signs in the dynamics of the families that they care for.
Nurses develop therapeutic relationships in order to support those suffering physical and psychological disease. It is vital that nurses also be trained in the specifics of properly supporting victims of CAN. Recovery from CAN is often a life-long process. Recovery is facilitated when those afflicted receive appropriate and caring support and guidance. Well meaning but poorly trained attempts to help victims can actually slow recovery, as when the affected child is advised to "just put it out of (his or her) mind" or "just get over it." This illustrates the importance of education in the proper methods for supporting and facilitating victim's recovery. Nurses may encounter CAN victims in the hospital, or may discover that they have identified a child at risk for or suffering CAN during school screenings or at a doctor's office visit. In these situations, nurses can begin the process of recovery of CAN victims by taking steps to build the affected child's self esteem. Ensuring that the child has a safe environment where his or her needs are met in a loving manner is a major priority. Nurses may also work with CAN victims in mental health units. Abused children often believe they are damaged, unlovable, and worthless (Valente, 2005). Nurses must constantly reinforce the idea that an affected child is worthwhile, lovable, valuable and deserving of loving care. It is crucial that nurses allow those suffering from CAN to speak openly about their experiences, and that when a victim reports abuse, they must be believed (American Humane Association, 2003).
Supporting recovery of victims is very important, but few would dispute that it is far better to prevent a situation that causes serious harm to a child from happening in the first place. This is especially true in CAN. No means of therapy exists that is superior to avoiding the experience of abuse trauma or neglect entirely. There are many ways to reduce the chance that children will suffer abuse or neglect. Preventative measures include the following: At schools, health fairs, or clinics, nurses can provide age appropriate educational materials on CAN to children. Children can be trained in problem solving techniques, taught to identify troublesome occurrences, and conditioned to believe in themselves. Parents can be educated in finding safe child care arrangements. The public at large can be taught that a child abuser is most often some one who is known to the child. For too long, efforts at avoiding CAN have centered on alerting children to "stranger danger," when in fact the danger most often comes from relatives or acquaintances (American Humane Association, 2003).
Child abuse and neglect is a significant and pervasive problem which causes devastating and long lasting damage to those affected. In their roles as patient advocates, nurses can make a real difference in the lives of children, through training in CAN recognition, and in the appropriate response to positive CAN screening results. Nurses can effectively support the recovery of those who are damaged by CAN, and can take meaningful action to stem the tide of CAN. As compassionate professionals who dedicate their lives to serving their patients, nurses are ideally suited to make the world of childhood brighter and safer for all children.
There are potential disadvantages to these interventions:
a- "Because nurses are on the forefront of assessment, they must be trained to recognize child abuse and neglect, and trained in the proper response to positive screening results".
i- Disadvantage 1: Inadequate Insurance. The cost of training nurses is already high. Health care receivers ultimately shoulder the burden of the education of heath care providers, either through insurance payments, or through direct payment for services. Every item that is added to a nursing school curriculum adds costs to that program, in terms of time and money. Insurance is already unaffordable for many people. Adding to the costs of healthcare would put insurance out of the reach of even more people. A survey of 1,712 college students revealed a 17% rate of occurrence of sexual abuse before age 18 (Epstein & Bottoms, 1998). Ending abuse for 17% of the population would involve a huge increase in insurance rates.
ii- Disadvantage 2: Discrimination. The poor have long had a saying: "Justice means 'just us'", meaning that fairness is only available to those who are prosperous and mainstream. Disenfranchised minorities would be vulnerable to any attempt to screen for abuse as they lack the money and power to appeal an inaccurate finding. According to Douglas Besharov in The Future of Children (1994), “Potential reporters are not expected to determine the truth of a child’s statements. As a general rule, therefore, all doubts should be resolved in favor of making a report.” This implies that every time a child made a statement indicating potential abuse, the parents of that child would inevitably face a removal process, and the costs of an appeal. Poor and minorities by definition do not have excess funding and power, therefore their children would be removed at rates much greater than prosperous members of mainstream culture.
b- "Nurses must be educated in methods of support for affected victims and in ways to prevent child abuse and neglect".
i- Disadvantage 1: Knowledge Deficit. Most nurses would not know where to begin in repairing the shattered psyche of an abused child. A knowledge deficit exists in the nursing community at large regarding what child abuse is and how to respond to it. To remedy this problem, programs are being developed to educate nurses in identification of the at-risk or victimized child (Young, Jackson, 2007), however these programs are still in development. ii- Disadvantage ii: Religion. Preventing child and abuse means that some of the power over decisions about a child is taken away from parents and given to government. Religions vary in their views on the roles of child and parent, however most religions advocate for submission of the child to the will of the parent. The Bible tells the story of Abraham, who was preparing to sacrifice the life of his son to God (Genesis 22:1-12 ). This action would not be condoned by a society that educates its nurses in preventing abuse, however that occurrence is a cornerstone of the Christian faith. The religious right believes that there is one ultimate authority for all things, and that authority is God. It would be expected that they would oppose the transfer of power from God to the government.
Child abuse and neglect is a complex problem. Finding solutions to this problem requires evaluation of the benefits and the drawbacks of potential interventions.

Besharov, D. J. (1994). Responding to child sexual abuse: The need for a balanced approach. In R .E. Behrman (Ed.), The future of children (Vols. 3 and 4) (pp. 135-155). Los Altos, CA: The Center for the Future of Children, The David and Lucile Packard Foundation.
Epstein, M., & Bottoms, B. (1998). Memories of childhood sexual abuse: A survey of young adults. Child Abuse & Neglect, 22(12), 1217-1238.
Genesis 22:1-12 , (1952). Holy Bible. Dallas, Texas: The Melton Book Company.
Young, C, & Jackson, E (2007). Innovative Learning Opportunity. Journal of Nursing Education, 46, Retrieved May 1, 2007, from http://proquest.umi.com/pqdweb? index=0&did= 1245472821&SrchMode=1&sid=2&Fmt=6&VInst= PROD&VType= PQD&RQ T=309&VName=PQD&TS=1180685630&clientId=3236.

1 comment:

gb said...

A very thoughtful article. Thanks for pointing out that nurses are excellent observers of child abuse (and thus can report it and stop it). Teachers need to become more skilled at being mandated reporters, too. When most teachers see signs of child abuse, they don't know how to talk to the child. So they frequently say the wrong thing, either scaring the child back into silence, or jeopardizing any future prosecution. A new online role-playing course tries to address this. It lets teachers rehearse a conversation with a possible child abuse victim, getting feedback after every choice. It's free (with a CEU-version for teachers). Maybe someone should do one of these for nurses, too....