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Subject: Psychiatry Topic: Diagnosis and

Management of Family Violence

Date: 08. 03. 2009 Lecturer: Dr. A.J.V.


Transcriber: guest No. Of Pages: 15 OUTLINE




From the powerpoint, recording (halong italics and bullets), and Kaplan 10th ed


A. Child Abuse B. Spouse Abuse C. Abuse of the Elderly


all forms of adult behaviour destructive to physical and psychological well-being, and normal growth and development of the child A. TYPES OF CHILD ABUSE 1. PHYSICAL o Act: non-accidental physical injury o Examples: a. Laceration b. Abrasions c. Cuts d. Fractures e. Dislocations f. Burns g. Bruises h. Hematomas i. Soft Tissue Swellings j. Strangulation Diagnosis and Management of Family Violence Page 1 of 15

o Munchausen Syndrome by Proxy child repeatedly brought to hospitals for treatment of peculiar or puzzling problems by overly cooperative parents
Parent induced the injury to the child and brought them to the hospital

o Factitious Disorder parents inflicts illness or causes injury to child by injecting toxins or inducing the child to ingest drugs this results to diarrhea, dehydration or other signs and symptoms seek medical consult o Diagnosis of Physical Abuse a. History Given incompatible history with PE being inconsistent, vague, mystery, none (suspect abuse) Doctor or Witness and child of same sex, Doctor should not be of same sex as perpetrator Put child at ease and explain how the PE is conducted Thorough, meticulous, gentle and slowly handling Allow child express feelings and ask questions Delay in seeking treatment Repeated injuries, hospitalization, laboratory examinations or injury avoided with supervision Failure to gain weight despite adequately eating (+) current family crisis (+) unrealistic/unreasonable parental demands from child

HPI, past medical history, ROS, psychosocial history b. Physical Examination Findings: Injury inadequately explained by history Document: Number, Color, Measure marks Bruises: Symmetrical patterns on face, back, butt, thigh Shape of instrument (belt buckle, cord, strangle) Burns: Cigarette, Iron, Socks and Gloves, Donut Laceration, Abrasions, Cuts, Hematomas, Soft Tissue Swellings
Retinal haemorrhages in an infant may be a result of shaking

c. Laboraties Xray: Skeletal Survey i. Fractures: Spiral fracture ii. Dislocation, Fractures Inability to move extremities CT Scan: Serum: Ultrasound: Coma, convulsions, dead d. Mental Status Examination Child alone without parents Withdrawn, frightened, aggressive, labile Depressed, anxious, poor self-esteem, cover up injuries, reticent to disclose abuse for fear of retaliation [some children think that their parent love them and this is how they show their love] Delayed development, different with peer relations, self-destructive, suicidal o Risk Factors of Physical Abuse a. Stressful living conditions Parental discord Overcrowding, Poverty, Unemployment Social isolation No support system b. Sociocultural acceptance of corporal punishment c. Culture of violence Video Music Politics Diagnosis and Management of Family Violence Page 2 of 15 Signs and symptoms of intracranial hemorrhage Retinal haemorrhages (shaking) Hypernatremia, dehydration (water deprivation) Signs and symptoms of ruptured stomach, bowel, liver, pancreas (abdominal trauma)

o Dynamics of the Physical Abuser [abuser most often is usually also abused] Identification with aggressor Mental disorder or PD Poor impulse control Low tolerance to frustration No outlet for anger or tension (+) Substance of Alcohol Abuse Ignorance Inappropriate expectation from child Reversal of dependency needs [the parent turns to the child for reassurance, nurturing, comfort and protection and
expects a loving response]

o Characteristics of the Physically Abused Premature Prolonged Hospitalization Mentally Retarded Physically Disabled Easily cry Unusually demanding Hyperactive Impulsive Difficult Moody Hardheaded

2. SEXUAL o Contact or interaction between child and adult when the child is used for sexual stimulation of the perpetrator o Examples a. Exhibitionism b. Voyeurism c. Pedophilia d. Sexual Intercourse e. Fondling f. Masturbation g. Oral Sex o Types of Sexual Abuse a. Assault Non-assault b. Intra-familial Extra-familial

Injury, Severe Emotional Trauma Little or no injury Between family members By one outside family known or unknown

o Acts of Lasciouvness a. Fondling b. Molestation c. Intentional Touch Patient Parts d. Introduction of Objects in Genitals, Anus, Mouth e. Bestiality f. Masturbation g. Exhibition of Genitals h. Voyeurism o Hiring child to a. Perform Obscene Exhibitions or Indescent Shows b. Pose, Act or Model in Pornography c. Child Prostitution d. Pedophilia o Incest sex intercourse between blood relatives or those related to each other by formal or informal kinship
[culturally regarded as a bar to sexual relations]

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Types a. Father - Daughter (75%) b. Father - Son (eldest) c. Grandparent Grandchild d. Sibling Sibling Exploratory Play e. Biological/Adopted/Step/Live in Partner/Steady Boyfriend/Girlfriend st nd f. Cousin Cousin: 1 and 2 g. Uncle Niece h. Aunt Nephew Variant of Pedophilia Rape Dynamics of Incest a. Family System - Hostile or Paranoid to outsiders - Social isolation - Precipitating stress - Vicarious repetition - Reversal of roles - Transgress generation bound b. Father - Inadequate personality - Puritanical or authoritarian - Violent or suspicious - Substance or alcohol abuse - Pre-genital fixation - Sex education c. Mother - absent, sick, incapacitated, passive - unaware, unbelieving, denial - collusive - fails to protect daughter, leaves daughter alone - lets father bathe daughter - lets daughter function as wife - mother sexual inhibition - also a victim of incest d. Father-Mother - emotionally deprived and needy leading to non-support and marital dissatisfaction - sex immature and inhibition resulting to problematic sexual relationship - illness of a spouse leading to frustration and resentment e. Daughter - daughter takes on the role of the mother (wife-surrogate) - secondary gains: affection, attention, privilege - sexualize relationships (eg. sex) means love - fear: separation, loss, abandonment, losing mothers love, blame for family breakup
DAUGHTER Confused relationship w/ father? Is father a parent or sexual partner? She is frightened that mother might blame or scold her MOTHER Basically caring of her children but may occasionally be competitive with daughter for husbands affection May not believe her daughter and afraid to confront her husband especially if she is financially dependent on him and even if she has some suspicion about it already passive/ blind FATHER Tends to be possessive of his daughter Shows he favors her by giving special privileges or showers with more expensive gifts Exempt from usual rules of the house and disciplinary measures SIBS Jealous of special position of incest victim, and affection father has for her In retaliation treat her as an outsider since they cannot get back at father / show their resentment to him as the more he will give them a hard time and will definitely side with the daughter /victim

DAUGHTER Bewildered Confused Frightened

MOTHER Caring Competitive Disbelief Afraid

SIBS Jealous Ostracize Sis

FATHER Possessive Favors D

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Perpetuating Factors for Incest - Motive of Abuser: Sex arousal by child - Silence: i. Maintain dysfunctional family unit ii. Prevent public shame - No intentional inhibitors: i. Morality ii. Religion - Decrease resistance in child due to: i. Helplessness ii. Secrecy iii. Entrapment iv. Delayed or Unconvincing Disclosure v. Retraction Social Factors that Perpetuate Incest i. Overcrowding ii. Rural isolation iii. Cultural tolerance iv. (+) mental disorder v. Intellectual defense vi. No external inhibitors: Protect patient - Reports: Low socioeconomic status due to contact with government agencies o Psychosocial Factors (Perpetuate Sexual Abuse) a. Abuser i. Known ii. Trusted iii. Family member with authority post iv. Wide access to child b. Child Victim i. Doesnt tell B/C guilt ii. Shame iii. Ignorance iv. Tolerance c. Family i. Fear of break up if abuse revealed d. Doctor i. Reluctant recognition and report e. Court i. Required strict rules of evidence o Sequelae of Sexual Abuse Depends on a. Type of Abuse b. Chronicity c. Age of Child d. Relationship of child with abuser e. Sense of Permanent damage o Diagnosis of Sexual Abuse a. History (+) Vaginal bleeding or discharge Other gynecological signs and symptoms in prepubertal girls (+) Frequent urinary tract infection Recurrent vaginal discharge (+) Pregnancy (+) Sexual acting out, promiscuous Know a lot regarding sexual act despite the age

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b. Laboratory C and S for vaginal discharge Urinalysis c. Physical Indicators on PE and External Genital Exam Bruises, Pain, Itching, Bleeding in the genital and rectal area Recurrent UTI, Vaginal Discharge and STD Difficulty walking or sitting d. Behavioral Indicators upon Observation and Mental Status Examination No specific psychological signs and symptoms universally indicative Detailed knowledge regarding sex present in play and repeat through peers Aggressive, hyperalert to extensive aggressive, homicidal, and suicidal behaviour Fear and distrust adults particularly men Phobia, PTSD, Anxiety, Depression, Dissociative Disorder, Borderline Personality Disorder, Substance Abuse

3. VERBAL o Examples a. Cursing b. Belittling c. Rejecting d. Insulting

Occurs in all types of abuse

o Acts or omissions which impaired psychological, intellectual growth and development of the child o Examples a. Behavioral b. Cognitive c. Emotional or Mental Disorders in a Child o Types of Emotional Abuse a. Reject childs worth or legitimate needs b. Isolate child from normal social experiences resulting to child feeling alone in the world c. Terrorize child by verbal assault, bullying, scaring d. Ignoring child emotional and developmental growth thru deprivation of stimulation and responsiveness e. Corrupt child by making child engage in destructive anti-social behaviour which is unfit for normal social experience

5. NEGLECT o Deprivation of Childs Welfare and Basic Needs (food, clothing, shelter, hygiene, education, medical attention) o This could result to failure to thrive o Lack supervision and care o Dynamics of Neglect a. Parent Overwhelm Depress Isolate Impoverished Unemployed Single Parent Substance Abuse b. Mother Inexperienced, Ignorant Chronically Passive, Withdrawn Chaotic, Abusive, Neglect Homes (Good Patients) (+) Mental Disorders, Thinks child is evil or purposely drives them crazy (Poor Patient)

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o Diagnosis of Neglect a. History Parents Perception of Childs Need vs Actual Need Example: Parent under estimate childs need leading to too little supervision Parent over estimates childs capacities resulting to child overachieve b. Physical Exam Malnourished Protruding abdomen Poor MM tone Skin cold and pale c. Laboratory Bone age retarded despite normal growth hormone d. Physical Indicators Inappropriate dress Poor hygiene Hungry Malnourished Chronic infection e. Behavioral Indicators Emotional development impaired Indiscriminately affectionate Socially unresponsive Sullen Quiet Depressed Runaway Conduct disorder o Types of Neglect a. Reactive Attachment Disorder of Infancy or Early Childhood (< 5 years old) Hypokinesis, Dull, Listless, Apathy Poverty of spontaneous activity Delayed response to stimulus Look sad, joyless, miserable Frightened, watchful, radar-like gaze Aberrant social behaviour Indifferent to separation Little interest in environment (-) play with toys b. Non-Organic Failure to Thrive (< 1 year old) Weight loss Fail to make expected weight gain due to inadequate food intake resulting to impairment of physical development rd Small based on standard growth charts below 3 percentile and appropriate weight for height c. Psychosocial Dwarfism (> 5 years old) Inimical or hostile parent-child relationship due to failure to form attachments before 2 years old Child cannot form lasting relations due to lack of guilt and the inability to obey rules Need for attention and affection due to disturbed social relations (ie. Indiscriminately Friendly) Due to chronic deprivation, doesnt grow or develop even if given adequate food Bizarre eating behaviour - Binge eating - Ingesting garbage or inedible substance - Drinking toilet water - Induce vomiting Reversible endocrine change leading to decrease growth hormone Normal proportions but too small or short for age

B. DIFFERENTIAL DIAGNOSIS o o o o Be careful not to over diagnose abuse Not all unexplained injury means child abuse Patients who are separating accuses each other Rule Out: Blood Dyscrasias, Vitamin Deficiencies, Other Medications Diagnosis and Management of Family Violence Page 7 of 15

C. MANAGEMENT Approach 1. Child o Establish rapport o Comprehensive psychiatric evaluation o Ensure safety and well being o Remove from family VS Added vulnerability in unfamiliar setting o Treatment of psychiatric disorder 2. Parent o Eliminate or diminish social or environmental stress o Reduce demands on mother o Emotional support, Encouragement, Sympathy, Stimulation o Education on child development and parenting skills o Resolve psychic conflicts a. Psychotherapy b. Individual Couple Therapy for Husband and Wife c. Family Treatment ER Management of Abuse o Crisis Intervention if suspect abuse Compassionate Data Gather a. History b. Physical Examination c. Neuroexamination d. Mental Status Examination e. Skeletal Survey f. Psychiatric Test Refer to a. Psychiatrist b. Pediatrician c. Surgery d. DSWD within 72 hours Report to Child Protection Unit Secure Child Safety - Admission to hospital VS Outpatient department Inform parents Arrange program of care for child and parent Arrange and guarantee follow up with social service, psychiatric, self help groups Long Term Management of Abuse o Help patient identification and moderate causative factors for abuse o Support individual psychotherapy, group therapy, self-help groups o Teach mothering, parenting o Last Resort Out of home placement if family unwilling or unable to work in therapy Management Goals of Abuse 1. Ascertain cause of family malfunction and overcome o protect child and rehabilitate patient 2. Approach o Compassionate o Understanding o Non-judgemental B/C both abused child and abusive parent Primary Prevention of Abuse o General Public 1. Public Awareness Campaigns 2. Schools 3. College 4. Child Welfare Legislation Diagnosis and Management of Family Violence Page 8 of 15

Identification of abuse and alternative to physical punishment Teach child to recognize abuse and respond assertively Marriage, Response of Parent, Child Development or Care, Family Life, Home making

Secondary Prevention of Abuse o High Risk 1. Single or Young Patient 2. Poor 3. Unemployed 4. Crowded o Perinatal Support Program o Parent Support Group o Social Support Services enhance mother-child bond facilitate friendships, establish social networks livelihood, child day care center, 24 hour crisis centers

o Educate Regarding 1. Parenting a. Child development b. Recognition when abusive or neglectful 2. Alternative Coping Strategies a. Anger and Stress management b. Relax c. Problem Solve Skills 3. Socialization and Communication Skills 4. Teach child a. Personal safety b. Community resources Tertiary Prevention of Abuse o Family for abused child Goal: Prevent recurrence and avoid harmful effects on child Substitute or foster care Family support services Psychotherapy for pathology of parent and trauma to child Legal: Punish perpetrator for crime or court ordered psychotherapy and rehabilitation


A. TYPES OF ABUSE 1. Physical o physical harm inflicted on woman 2. Sexual o any sex act done against the womans wishes 3. Verbal o degrading, insulting, threatening, accusing, humiliating, blaming, yelling 4. Emotional o ignoring, bringing of querida, no sexual contact, social isolation, over-control, angry, possessiveness, pressuring 5. Financial o refuse to give basic needs or money, leaving debts, forcing woman to quit work, deprive her of inheritance

B. CYCLE OF ABUSE Phase I: Tension Building Diagnosis and Management of Family Violence Page 9 of 15 He is afraid that she will leave him Knows his behaviour is inappropriate He is greatly jealous and possessive Finds fault, gets angry and blames her




C. DYNAMICS OF THE ABUSIVE PARTNER Build up low self-esteem and inadequacy Threatened manhood Immature, dependent, non-assertive Impatient, impulsive Displace anger and aggression Identification with aggressor Testing behaviour

power and control humiliate wife, assert head of family

D. HOW SPOUSE HOLD POWER AND CONTROL 1. Isolation o Jealousy o Wife cannot go out, or see friends and family o Intimidate family or friends not to visit 2. Eco Dependence o Keep wifes money o Not employed o Spend family income recklessly o Gamble o Destroy wifes property or valuables 3. Privilege o Take advantage of wifes oppressed status 4. Religion o Justify abuse o Cast spell or curses on wife o Guilt trip o Marriage vow o Church 5. Children o Wife stay to protect child from abuse o Husband threat to take or harm child 6. Physical o Threat to kill wife o Physical harassment (ie. Not let wife sleep, drive dangerously) 7. Emotional Diagnosis and Management of Family Violence Page 10 of 15

o Scare or intimidate wife o Make her feel stupid, helpless, crazy, always wrong o Play mind games

E. WHY WIFE STAYS IN ABUSIVE RELATIONSHIP? 1. 2. 3. 4. 5. 6. 7. 8. Eco dependence and social security Religious or Cult: Fear or Shame Identification as wife, sex roles stereotypes Duty to family, responsibility to child Pity, love and loyalty to husband Depression, passive, learned helplessness Came from violent homes leading to negative self confidence or esteem or worth or respect Denial, hope for change

F. EFFECTS OF DOMESTIC VIOLENCE On Wife o Effects a. low self esteem b. negative self worth c. blame self d. negative self image e. I deserve this f. depression g. drug or alcohol use h. isolation i. fear or reprisals or further abuse j. helplessness k. passive o Leads to a. Illness b. Pain c. Injuries d. Permanent Physical Damage e. Death On Child o Effects a. fears b. anger c. identification with aggressor d. acting out o Lead to a. Illness b. Injuries c. Death On Husband o Repeated battering

G. MANAGEMENT OF SPOUSE ABUSE Wife o must decide No to Abuse!! o prolonged stay away from husband o shelter with child o find work o help from police and DSWD supportive or insight oriented psychotherapy o family treatment Husband o treatment-condition of return o treat psychiatric disorder o aggression or tension release If wife abusing husband: financial aid [rare case] H. CYCLE OF VIOLENCE Diagnosis and Management of Family Violence Page 11 of 15




I. SEXUAL ABUSE OF ADULTS RAPE o forceful coercion of unwilling victim to engage in sexual act (sex intercourse, anal intercourse, fellatio o full erect and ejaculation not necessary to be crime o act of violence and aggression express through sex o marital or homosexual 1. Rape of Men [men started to wonder if they are homosexual] a. Sodomy b. Fellatio 2. Homosexual Rape Close institutional prisons, maximum security hospital Rapist: Victim: Discharge aggression and aggrandize self Smaller, passive, unmanly

Fear of homosexual, feel damaged 3. Rape of Women Under reported due to shame and mistrust of legal system Mostly premeditated Committed by strangers Life threatening Lead to: a. Post Traumatic Stress Disorder b. Phobia c. Vaginismus Degree of Emotional Damage Depends on: a. Violence of Rape Attack b. Vulnerability of Woman c. Support System Availability Immediately After Reaction a. Shame b. Humiliation c. Confusion d. Shock e. Fear f. Fright g. Panic h. Rage o Dynamics of Rapist Sexual Sadist Exploitative Predators Inadequate Men

Aroused by pain of victims Victims as object of gratification in impulsive way Believe no woman would sleep with them unless by force and obsessed with sex fantasies Displaced expression of anger and rage Anger to men, mother and wife is displaced to other women Women is visualized as mens property or possession, instrument of revenge

o Date Rape Warning Signs and Symptoms of Dating Violence Diagnosis and Management of Family Violence Page 12 of 15

- If boyfriend is: a. Acting jealous or possessive b. Not taking NO for an answer c. Controlling social contacts d. Putting date or friends or family down e. Making all the decisions f. Imposing traditional sex roles g. Driving fast or doing scary things h. Accusing date or girlfriend of lying i. Behavior i. Threatening ii. Manipulating iii. Controlling iv. Embarrassing v. Blaming j. Unpredictable or Erratic Mood or Behavior Example: Walking on eggshells to prevent partner from getting angry k. Refuse to discuss feelings then blow up, get angry or be violent after alcohol or drug intake Tips for Safer Dating a. Trust your instincts b. Have safety plan c. Meet in public places d. Tell someone where you go and who youre with e. Keep in touch with friends and family f. Be assertive and leave if uncomfortable g. Have transportation, money for ride or call h. Know where you are i. Know date before going out alone j. Avoid situations that could lead to rape o Management of Rape a. Individual Psychotherapy Emotional and Social Support Reassure not her fault Restore sense of adequacy and control over life Ventilate and relieve feelings of helplessness, dependence and obsession with assault b. Group Therapy Rapist may be: i. Imprisoned ii. Court ordered psychotherapy iii. Medication STALKING o pattern of menacing behavior with threat to do harm that lasted for months or years o Do 1. Report to police 2. Counselling for the stalkers SEXUAL HARRASSMENT o Sexual Advances o Requests for Sexual Favors o Verbal or Physical Conduct of sex nature unwelcomed by victim examples: abusive language, sexual jokes, staring, ogling, giving massage o Work Place Perpetrator: 95% are men o Victim: Mostly women 1. Blames selves 2. Depressed 3. Anxious 4. Angry o Do: 1. Educate 2. Investigate complaints 3. Organization action a. Written Reprimand b. Fire


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act or omission that harms the health or welfare of elderly A. TYPES OF ELDERLY ABUSE 1. Physical o Any act that results to physical injury o Physical restraints o Inadequate ventilation or heating o Manifestation a. Bruises in variant stages of healing b. Bilateral pattern c. Punctures 2. Sexual 3. Emotional o Threats, insults, harassment o Withhold security and affection o Harsh orders o Social isolation, not allowing travel, visit, or attending church o Manifestation a. Resignation b. Fear c. Depression d. Anger e. Confusion f. Insomnia g. Ambivalence 4. Financial o Misuse income or resources 5. Medical o Withhold or improper administration of medication, therapy, health aids o Manifestation a. Lethargy b. Confusion c. Disorient d. Memory impairment e. Agitation f. Cant eat g. Hear h. Walk i. Vaginal Discharge 6. Neglect o Deprive of care necessary to maintain physical and mental health o Example a. Withhold food and water b. Unclean clothes and beddings o Manifestation a. Malnourished b. Dehydration c. Poor personal hygiene

B. PSYCHOSOCIAL FACTORS Family Conflicts Frail and weak victims Live with assailants o Financial dependence on victim Both deny or minimize presence of abuse

C. MANAGEMENT Diagnosis and Management of Family Violence Page 14 of 15

Legal or social services Housing Medical evaluation and treatment Psychiatric evaluation and treatment

Elderly or someone truly concerned 1. Seek legal counsel to protect his or her rights and best interest nd 2. Seek 2 opinion if someone had labelled them as incompetent or insane 3. Change guardian 4. Social services should do home visits to ensure that elderly has proper care.

-END OF TRANSCRIPTIONWeve been together for three years. We have passed many difficulties and challenges, yet we have been triumphant in most of our aims. Together we can surpass anything, together we can be successful in everything we set our minds into. We just have to learn to think as one group, to help one another, and not just ourselves. Malapit na sembreak pero semestrals muna. Good luck and God bless. PS: Dianne, ayoko na pala magtranx. =p

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