Ask the Expert

Children and Violence

Barbara Kelley and Michelle Beauchesne Column Editor: Ann Froese-Fretz

Ask the Expert provides answers to clinical questions for nurses in practice settings. Where possible, evidence from restnrch is used to support the experts‘ recommendations.

Question: Should violence prevention be included in anticipatory guidance of well children?

Barbara Kelley and Michelle Beauchesne respond: The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have declared violence prevention a public health priority (Foege, Rosenberg, & Mercy, 1995; World Health Assembly, 1996). The public health approach to vio- lence prevention is based on interventions (treatments) and prevention, both of which depend on assessment and evaluation of individual, family, and community risks. Nurses need to include questions about violence as part of any health assessment of the child and family. Violence prevention should be as much a part of antici- patory guidance as are lead-poisoning prevention or immunization education. Most healthcare providers do not a d h this issue because they are not s w how to ask the questions or what to do with the information once collected (Beauchesne, Kelley, Lawrence, & Farquharson, 1997).

Assessment

Shingham (1 995) has developed a developmental approach to history taking that identifies key questions to ask at each developmental level. In the case of very young children, parents or caregivers must be asked questions about violence. By focusing on family con- flicts and interpersonal relationships, the nurse can identify feelings of anger or inappropriate behaviors that pose potential threats of violence to infants and children. Assessing the cultural values of the family and their interactions regarding parenting, communication, decision making, limit setting, and family roles provides the nurse with information on family dynamics and affords the opportunity to help strengthen family bonds.

In addition to cultural values and beliefs, the pediatric nurse should assess the overall environment in which the child is to be raised. Is the family living in poverty with very limited resources? AR there guns or weapons in close proximity to the growing child? Helping the par- ents provide a safe h d t h environment is a nuIsing con- cern. Has there been a history of violence within the extended family or kinship system? Is there a problem with violence in the neighborhood or community? What support systems exist for help?

As the child grows, the list of questions should reflect the potential amas of conflict between panmt and child, such as safety issues surrounding crawling and walk- ing, a toddler’s negative responses, toilet training, and sleep issues. Assessment should include the parent‘s choices of baby sitters and daycare placements. As the child spends more time out of the home, the external environment should be assessed. Is the neighborhood safe? Are the parents concerned about the child‘s friends? What control does the parent have regarding the child’s choice of books, television viewing, movies, and sports participation? What about the adolescent’s choice of dating partners and knowledge of appropriate dating behaviors?

It is helpful for the nurse to have a repertoire of simple, direct, nonjudgmental questions to use. ‘Tell me what you do when your baby cries.“ “What do you do for your baby if the crying doesn‘t stop?” ’Who gets up if the baby cries at night?” ‘Who else is there to help you with your baby?” “What do you do for yourself when you are feeling angry and frus- trated with your baby?“ Remember to let parents know that it is normal to feel upset and angry, and problem solve with them what they can do when it happens.

Children also must be afforded the opportunity to talk about possible fears and anxieties regarding their envi- ronment and the people around them. By asking ques- tions about safety and violence, the n m is modeling for parents how to talk about violence to children as well as helping children idenbfy and seek out safe adults should they need help.

JSPN VOL 3, NO. 3, July-Septembf% 1998 127

Ask the Expert

Identifying Children/Families at Risk

Witnessing violence may produce a variety of behav- ioral and emotional effects that must be distinguished from organic illness. Some children may exhibit signs and symptoms of posttraumatic stress disorder (PTSD), which manifest as diminished ability to concentrate in school, persistent disturbances in sleep, flashback memo- ries, disordered attachment behaviors, hyperarousal, hyperalertness, feelings of hopelessness, eating disorders and increased risk taking disorders (Beauchesne et al., 1997; Groves, Zuckerman, & Marcus, 1993). The severity and intensity of the signs and symptoms depend on sev- eral factors: proximity of the event, the victim’s relation- ship with the child, and the presence or absence of a mediator.

Research has shown a relationship between violence and eating disorders, developmental regressions, cogni- tive or language delays, secondary enuresis, increased physical complaints such as headache or stomachache and sleep disorders (Augustyn, Groves, Parker, & Zuckerman, 1995). Children witnessing violence will respond differently according to developmental age. Infants living with their mothers in shelters for battered women have been described clinically as being in poor health, with weight and eating problems, poor sleeping habits, and excessive screaming (Hilton, 1992).

Parents or caregivers who are under stress from other sources, such as financial or interpersonal, may find it even more difficult and frustrating to deal with the often intense needs of an infant. Shaking an infant or child in anger and frustration is an inappropriate response on the part of many caregivers to such stress. However, as understandable as the frustration may be, it is never OK to shake a child, especially an infant. A caregiver who reaches the point of severe frustration without thinking of the consequences may shake an infant who, because of a heavy head, weak neck muscles, a soft and rapidly growing brain, and thin skull wall, is extremely vulnera- ble to injuries from shaking. This results in a condition called shaken baby syndrome or impact syndrome (Couser, 1994).

Crying, particularly the constant crying of a colicky baby, is the behavior that most often triggers an episode of severe shaking. Nurses must learn to recognize the signs and symptoms of shaken baby syndrome. We know certain risk factors have been identified, such as infants younger than 6 months who most often have male care- givers (70% of abuse cases), day-care providers (babysit- ter, 20% of abuse cases), and single working parents.

keschoolers who have witnessed repeated episodes of violence have been described as showing signs of terror: yelling, irritable behavior, hiding, shaking, and stuttering (Buchsbaum & Emde, 1990; Gainer & Power, 1996). These young children also are likely to express somatic com- plaints and regress to earlier stages of functioning. Preschool children initially may appear withdrawn, sub- dued, or mute; exhibit anxiety, attachment nightmares; and engage in repetitive play that focuses on an event.

School-age children may behave more inconsistently; those who were outgoing may become more reserved, more initable, have more fights and more vague somatic complaints of headaches and stomachaches, and exhibit decreased school performance. School-age children engage in a variety of responses to family violence. They suffer the dilemma of being embarrassed and ashamed of the “family secret” of violence, while hoping someone will uncover this information and rescue them. Children this age also may suffer guilt at not having been good enough so as to prevent the adults from getting mad. School-age children focus on both the actual event and the circumstances and may become uncooperative, sus- picious, and engage in risk- taking behavior (Beauchesne & Kelley, in press; Emde, 1994).

Adolescents are particularly vulnerable. Although they may learn violent behavior earlier, it is this developmental state where children are most susceptible to consequences due to separation from family, peer pressure, overidentifi- cation with gender stemtypes, and developing sexuality. Adolescents express rage, betrayal, rebelliousness, and antisocial behaviors. Majonis (1991) found that behav- iors - including considering or attempting suicide, run- ning away, laxative use, and vomiting to lose weight - were strongly associated with a history of abuse.

128 JSPN Vol. 3, No. 3, July-September, 1998

Nurses can promote positive development by chan- neling risk- taking behavior in a nonthreatening direc- tion. Peer groups and counseling are especially effective community measures (Spivak, 1992). Nurses are in a position to play a pivotal role in violence prevention in children and families. Issues surrounding violence must be addressed in all phases of anticipatory guidance in child care.

Barbara Kelley, EdD, RN, MPH, CPNP, Michelle Beauchesne, DNSc, RN, PNP

Associate Professors, Primary Care Specialization College of Nursing

Northeastern University Boston, h4A

References

Augustyn, M., Groves, B., Parker, S., & Zuckerman, B. (1995). Silent vic- tims revisited: The special case of domestic violence. Pediatrics, 96, 511-513.

Beauchesne, M., & Kelley, B. (In press). Family violence reduction. In M. Craft-Rosenberg & J. Denehy (Eds.), Nursing interventions for childbearing and childrenring families. Thousand Oaks, CA Sage.

Beauchesne, M., Kelley, B., Lawrence, P., & Farquharson, P. (1997). Violence prevention: A community approach. Iournal of Pediatric Health Care, 22,155-164.

Buchsbaum, H., & Emde, R. (1990). Play narratives in 36-month-old children: Early moral development and family relationships. Psychoanalytic Study on the Child, 40,129-155.

Couser, S. (1994). Shaken baby syndrome. Journal of Pediatric Health Care, 7, 238-239.

Emde, R. (1994). The horror! The homr! Reflections on our culture of violence and its implications for early development and morality. Psychiatry, 56,119-123.

Foege, W., Rosenberg, M., & Mercy, J. (1995). Public health and violence prevention. Current lssues in Public Health, 2 , 2-9.

Gainer, P., & Power, T. (1996). Preschoolers’ emotional control in the disappointment paradigm and its relation to temperament, emo- tional- knowledge, and family aggressiveness. Child Dmelopment, 67,1406-1419.

Groves, B., Zuckerman, B., & Marcus, S. (1993). Silent victims: Children who witness violence. JAMA, 269,262-265.

Hilton, N., (1992). Battered women’s concerns about their children wit- nessing wife assault. Journal of lnterpersonal Violence, 7, 77-86.

Majonis, J. (1991). Discipline and socialization of children in abusive and non-abusive families. Child and Adolescent Social Work, 8, 203 -224.

Spivak, H. (1992). Community approaches to violence prevention. In D. Schwarz (Ed.), Children and violence (pp. 107-117). Columbus, OH: Ross Laboratories.

Stringham, P. (1995). Guide to violence preziention and treatment. East Boston, MA: East Boston Neighborhood Health Center.

World Health Assembly. (1996). prevention of violence: Public health priority (Resolution No. WHA 49, 25). Geneva: World Health Organization.

Questions? Do you have a question about something you encounter in your clinical practice? Send it to:

Ann Froese-Fretz, MS, RN, CPNP The Children’s Hospital 1056 E. 19th Ave., BllO Denver, CO 80218

I froese- fretz.ann@tchden.org

Save the Date April 25-28/1999

Society of Pediatric Nurses National Conference

Houston,Texas

”Pediatric Nursing Opportunities, Vision and Advancement”

Contact SPN:

www.pednurse.org 800 / 723-2902

JSPN Vol. 3, No. 3, July-September, 1998