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Paper Abstract: Discusses the problem of abuse of school age children. Reviews the historical background. Examines the scope of the problem. Factors that place children at risk for physical abuse. Proposes three health promotion strategies to prevent abuse., including family therapy, anger management, child development. Presents research to support each strategy. Abstract. Paper Introduction: ABSTRACT This paper examined the problem of physical abuse in school-age children. The paper began with a brief historical description of the problem, noting that it was not really until the later part of this century that the problem was fully recognized. This review of the historical background of the problem was followed by an examination of the scope of the problem, the psychoemotional and physical effects of the problem, an epidemiological discussion, and a delineation of several factors that place children at risk for physical abuse. The problem was shown to be both substantial and complex in nature. The second section of the paper proposed three health promotion strategies for remediating the problem of physical abuse in childhood. These strategies were: (1) a primary prevention screening strateg Text of the Paper: The entire text of the paper is shown below. However, the text is somewhat scrambled. We want to give you as much information as we possibly can about our papers and essays, but we cannot give them away for free. In the text below you will find that while disordered, many of the phrases are essentially intact. From this text you will be able to get a solid sense of the writing style, the concepts addressed, and the sources used in the research paper. National Institute of Justice. (1986). 5. The second section of the paper proposed three health promotionstrategies for remediating the problem of physical abuse in childhood.These strategies were: (1) a primary prevention screening strategy to beused to identify families at risk for abuse; (2) a secondary preventionstrategy aimed at improving parents' knowledge of childhood development aswell as their anger management and disciplinary skills; and (3) a tertiaryprevention family counseling strategy. Rodriguez andSutherland (1999) report that substance abusing parents are almost threetimes likelier to be physically abusive than are parents who are notsubstance abusers. Measures used in monitoring were instruments assessing levelof parental anger and physical discipline/force, and family problems. According to Krowchuk (1999),most abusers are neither psychotics or criminals. The therapeutictreatment provided in cases involving physical child abuse: a descriptionof current practices. Di Scala, C. If the program is effective, it would be expected thatparents would show statistically significant gains on each of the measures.Tertiary Prevention Strategy The third strategy selected is a standard intervention strategy aimedat not only stopping the abuse but also helping the abusive parent to dealwith those psychoemotional conditions that have given rise to the abuse.This is the strategy of counseling or psychotherapy. al (1998) that children receive at least as many weeklysessions of focused family counseling/psychotherapy sessions as theparents. & Labruna, V. Itcan be noted here that there does exist research indicating that programsdesigned to prove abusive parents' knowledge and skills can be successful.For example, Landis (1999) found that a parenting skills interventionprogram designed for abusive parents led to significant improvements inparents' disciplinary techniques, their parent-child communications andinteractions, their coping skills, and their general knowledge of childrendevelopment processes. About 27 percent of all children physically abused are schoolage children between the ages of 8 and 12. Government assistance in the 193 s tomothers and children lessened the need for this sort of intervention. Parental evidence of poor impulse control or fear of losingcontrol. U.S. Applied Nursing Research, 2(1), 35-39. Abuse of mother by father. On the last day of this program, parentswould be posttested on all measures. Child abuse and unintentional injuries: A 1 -Year retrospective. The need for such a long program with so manysessions devoted to remediating the effects of the abuse on the child comesfrom a study of the current practices of mental health professions in casesinvolving physical child abuse treatment, at least in part, by familytherapy. Archives of Pediatric and Adolescent Medicine, 154(1),16-22. First and foremost of these is physical injury. Background Paper # 3. No. Further,they are more likely to have longer hospital stays, to go to developextensive functional limitations, and to have worse survival outcomes thannon-physically abused children. (1997). Greenwalt, B.C., Sklare, G. This review of the historical background of the problem was followedby an examination of the scope of the problem, the psychoemotional andphysical effects of the problem, an epidemiological discussion, and adelineation of several factors that place children at risk for physicalabuse. (1994). 6. The longer the abusecontinues, the more serious the injuries to the child and the moredifficult it is to eliminate the abusive behavior. Kaplan, S.J., Pelcovitz, D. Masters Abstracts, 37(5), p.1361. Italso provides a summary of the three developed health promotion strategies. The problem was shown to be both substantial and complex in nature. In this regard,Di Scala (2 ) reports that physically abused children are more likelythan non-physically abused children to suffer some form of intracranialinjury, and thoracic and abdominal injuries. Physical abuse injuries tend to result frompunching, beating, kicking, biting, or burning. PartI: Physical and emotional abuse and neglect. They are often more demanding and cry more than otherchildren. What is needed, Kolko states, is a weekly assessmentof high-risk indicators which allows for monitoring the course oftreatment. Department of Health and Human Services. If interview findings indicate that assessment levels are high, inconsultation with the clinic physician treating the family, referrals wouldbe made to multiple resources aimed at teaching parenting skills, andstrengthening all family members so as to cope more effectively with lifestressors and demands. Department of Health and Human Services. Document available:www.ojp.usdoj.gov/nij/childabuse/bg3d.html. In about 25 percent of the cases, reports come from eitherrelatives or the child him- or herself. HEALTH CARE GOALS FOR THE NATION---YEAR 2 2 THE PROBLEM OF PHYSICAL ABUSE OF SCHOOL AGE CHILDREN Problem Statement According to the National Institute of Justice (2 ), thecriminalization of child abuse and neglect began with the social reforms ofthe late 19th century and early 2 th century in which neglected and abusedchildren were removed from poorhouses or inadequate housing and placed ininstitutions or substitute care. The presence of multiple stressors on the family. Siegel, R.M., Hill, T.D., Henderson, V.A., Ernst, H.M. The parent may simplybe unaware of the magnitude of force with which he or she strikes a child.Most parents want to be good parents but sometimes lose control and areunable to cope; moreover, they are most likely to lose this ability in thepresence of certain environmental stressors such as job loss, conflict inthe home. Screening for domestic violence in the community pediatric setting.Pediatrics, 1 4(4, Pt. 4. Many were themselves mistreated in childhoodand felt rejected by their parents (About one-third of all physicallyabused children will go on to be abusers themselves). Based on the literature earlierreviewed, this program could consist of the following: Program Components Time Child Development Teaching 6 weeks in length Anger Management Teaching 6 weeks in length Instruction in effective discipline techniques 6 weeks in length Overview of learned material 2 weeks It is expected that through exposure to this clinic program, abusiveparents' skills in the areas of discipline, and the ability to manage theiranger, plus their general knowledge of child development, would improve. PublicHealth Service. In America, children under eight years of age tend to be morefrequently neglected than abused whereas school-aged children tend to bemore frequently physically abused than neglected. Logan, B.B. Regarding common patterns, parents who are physically abusive oftenhave certain personality characteristics. Thus, these would be the primaryobjectives of the developed program. Child abuse intervention:Strategic planning meeting. Further, research was cited tosupport each developed strategy as an effective avenue for interventionwith respect to the physical abuse of children. Parentswould then receive the program. Each program was described and a possible means of evaluating theprogram for effectiveness was provided. Nonetheless, for most of this century, the use of physical force to"educate" or discipline a child was accepted by the law as a privateprerogative of a parent, the limiting of which was thought to undermine thefamily. 3. Fears the child isn't meeting parental standards or expectations. They are usuallyignorant of normal child development and proper disciplinary strategies.Moreover, these individuals often expect their child to care for them andbecome confrontational when this does not happen. & Boat, B.W.(1999). Appearance of detachment 7. This study, conducted by Greenwalt, Sklare and Portes (1998) foundthat within 23 weeks of family therapy, parents are usually much improvedand had dealt with some of the crucial psychoemotional issues giving riseto the abuse. (199 ). Pretest and posttest comparisons wouldthen be made. (1998). If the nurse or other health professional conducting the screeningfeels sufficient numbers of indicators are present, he or she would then goon to conduct an interview with the parents, looking for the followingadditional indicators: 1. Child andadolescent abuse and neglect research: a review of the past 1 years. In the 196 s, however, new theories about physical abuse werepopularized by the medical community, and laws to detect and preventphysical abuse multiplied. All developed programs weregrounded in the existing literature on physical abuse in childhood(especially as it related to school-age children) and in the literature onsuccessful interventions for the problem. Menlo Park, CA: Addison-Wesley. Specifically, findings showed that not onlydid parents become better able to manage their anger, but both physical andverbal aggression in interactions within the family fell by substantialamounts. References Brayden, R.M., Altmeier, W.A., Dietrich, M.S., Tucker, D.D.,Christensen, M.J., McLaughlin, F.J. (1999). Fetsch, R.J., Schultz, C.J. Further, to make sure that anyobtained gains in these areas were maintained, additional posttest measurescould be taken again three and six months following the termination oftreatment. Child abuser stereotypes: consensus amongclinicians. Government Printing Office.----------------------- 1 U.S. Washington,D.C.: U.S. In terms of causal considerations, Howing et. (1996). And concern over the problem, along withinterventions designed to reduce it in society continues to this day.Scope of the Problem The Unites States Department of Health and Human Services (DHHS,1997) defines physical child abuse as deliberate physical injuryperpetrated upon a child. Psychological and emotional disorders are also associated with thephysical abuse of children. Indeed, according toBrayden, Altemeier, Dietrich, Tucker, Christensen, McLaughlin and Sherrod(1993), the most successful programs for abusive parents always includesome form of counseling or psychotherapy given to both the abusive parentand the abused child. In terms of evaluating the effectiveness of the familytherapy strategy overall, initial or pretest measures of parental anger andthe use of physical discipline could be compared to the final measurementtaken at the termination of treatment. However, they do tend tobe lonely, unhappy, depressed, angry, dissatisfied and isolated individualsexperiencing strong stressors. Health Promotion Strategies The three strategies developed and reported upon here for dealingwith the problem of child physical abuse of school-age children consists ofa primary prevention strategy, a secondary prevention strategy, and atertiary prevention strategy. Childabuse and delinquency: The empirical and theoretical links. (1993). In terms of program specifics, an extensive literature reviewconducted by Kaplan, Pelcovitz and Labruna (1999) of treatment for physicaland emotional abuse and neglect indicated that the following components arepart of effective family therapy given to abusive families: focusing on thearea where mothers feeling they need physical and emotional support anddesigning ways in which they can receive this support; helping familymembers to interact with one another in more functional ways; working to re-establish trust between family members; and providing families with lots ofpositive feedback for changes made. ABSTRACT This paper examined the problem of physical abuse in school-agechildren. Butz (1993) reports that typically these are low-birthweight infantswith hyperactivity, mental retardation, physical handicaps, or simplydevelopmental lag. To this end, a program of 5 weekly family therapy sessions could bedeveloped with about half of these focusing on the parents and the otherhalf focusing on the child. The paper began with a brief historical description of theproblem, noting that it was not really until the later part of this centurythat the problem was fully recognized. Child Abuse and Neglect, 22(1), 71-78. Do they feel that the problem hasbeen taken care of or gotten more under control? They are also more likely tohave more severe injuries than non-physically abused children. Interpersonal violence: A comprehensive modelin a hospital setting---from policy to program. (1999). Changes in parenting skills after participatingin a paraprofessional in-home support program. Krowchuk, H.V. It is stated that hospitals and family clinics shouldroutinely assess or screen school-age children with presenting injuries forphysical abuse risks. (1999). 2. Family centered nursing in thecommunity. The authors report that the majority ofperpetrators of child physical abuse tend to be parents, followed byrelatives or others in a position of providing care to children. Given the foregoing, the developed program would include a weeklymonitoring element. (2 ). An evaluative method for determining the effectiveness of eachstrategy was also developed and described. Abusive parents, Krowchuk (1999) states, often hate themselves forwhat they do but feel powerless to stop the behavior. In Surgeon General'sworkshop on violence and public health report (DHHS Pub. Kolko, D.J. In general, they are notgood problem solvers. (1986). Landis, S.M. It was also found that parents reported increased knowledge ofchildren and child development and a decrease in their unrealisticexpectations of their children. The basic aim of this primary strategy is to identify children (andtheir families) who are at risk for physical abuse and to then refer themto treatment agencies designed to intervene in preventing the problem;thus, the effectiveness of the strategy should be assessed so as todetermine whether it met these goals. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 39(1 ), 1214-1222. According to the DHHS (1997), approximately one million children eachyear are substantiated as having been physically abused (3 million per yearare reported) with most cases being reported by professionals, includingeducators, law enforcement, and justice officials, medical and mentalhealth professionals, social service professionals, and child careproviders. First, nurses would screen for the following indicatorsof physical abuse in children: (1) Unexplained injuries (e.g., burns, bitemarks, subdural hematomas, old or recent fractures, etc.); (2) dehydrationor malnourishment without obvious cause; (3) Ingestion of inappropriatefood or drugs; (4) evidence of general poor hygiene; (5) the presence ofstrong fear of the nurse or others; (6) reports by the child of physicalabuse; (7) old injuries not mentioned in the child's history; and (8) atendency of the child to take care of the parent or speak for the parent. At long last the physical abuse of children wasbecoming a national priority. Social Work,35(3), 244-249. Bydoing this, the authors were able, in many cases, to stop a potentiallythreatening problem before it turned into abuse. It is also noted by theDHHS (1999) that boys and girls are physically abused with roughly the samefrequencies, and that abuse transcends socioeconomic status; although thosewith at lower socioeconomic levels are said to have high risks only becausethey are subject to more environmental stressors. Both CBT and FT were foundto be effective strategies therapeutically. Isolation of the family from friends, relatives, and neighbors. One way this might be done would beto periodically survey family members referred for services to see if theywere helped and, if so, to what extent they were helped. Sirotnak, A.P. In Kolko's (1996) study of abusive parents of school aged children,the weekly monitoring technique was used for parents receiving eitherIndividual Child and Parent Cognitive-Behavioral Treatment (CBT) or FamilyTherapy (FT). While most programs can be assessed following the program'stermination, Kolko (1996) has suggested that this is insufficient whenworking with abusive parents, especially if the children have already beenreturned to parents. Journal of Pediatrics,122(4), 511-516. The paper ends with a short summary of the nature of the problem. * immaturity of caretakers (parents) * lack of parenting skills * unrealistic expectations of parents for children's behavior * parental history of physical abuse * social isolation of family * frequent family crises * parental alcohol or drug problemsEpidemiology Howing, Wodarski, Kurtz and Gaudin (199 ) state that childhoodphysical abuse is most often a function of an interaction between thecharacteristics of the child, the characteristics of the perpetrator, andstresses in the environment. Pediatric Review, 15(1 ), 394-399. On the other hand, children were commonly treated in only about sevensessions and the authors found that this was simply ineffective in trulydealing with the trauma the child experienced. Each of these along with methods forevaluating their effectiveness are presented below.Primary Prevention Strategy According to Sirotnak and Krugman (1994), a key strategy in theprimary prevention of childhood physical abuse is screening or assessmentof risk factors. Commonlyperpetrators are females under the age of 4 . Thisprogram would aim at those knowledge and skill areas the literatureindicates to be weakest in abusive parents. & Portes, P. Unresolved negative feelings about having a child. & Krugman, R.D. 1), 974-877. Reports fromthe States to the National Child Abuse and Neglect Data System. A prospectivestudy of secondary prevention of child maltreatment. They also commonly show some sort of delay in speech. Howing, P.T., Wodarski, J.S., Kurtz, P.D & Gaudin, J.M. Similar findings were reported by Fetsch, Schultz and Wahler (1999)in their evaluation of a parenting and anger management program provided toabusive parents in Colorado. Physical abuse of children: Anupdate. One possible health promotion strategythat could be used would consist of a 24 week long program for parentsreferred to a clinic by the courts for child physical abuse offenses. The DHHS suggests thatdata on the numbers of children who are physically abused each year areprobably conservative estimates since not all cases of physical abuse ofchildren are reported.Effects of Physical Abuse on School Age Children Several quite negative effects arise from physical abuse inchildhood. This was followed bythe development of three health promotion strategies which were: (1) A screening strategy for identifying families at risk forcommitting abuse; (2) Aa psychoeducational strategy aimed at teaching parents moreabout child development processes as well better anger management anddisciplinary skills; and (3) A psychotherapeutic family counseling strategy. (1999). Indeed, the authors report that an estimated 5 to 8 percent of all child abuse cases involve some degree of substance abuse onthe part of the child's parents. Based on the research on assessment indicators of physical abuse(e.g., Logan and Dawkins, 1986; Klingbeil, 1986), the strategy developedhere is two-fold. Summary This report examined the problem of child abuse in school agechildren, delineating and discussing the history and scope of the problemas well as risk factors and epidemiological concerns. Parents who are substance abusers are also more likely to losecontrol and go too far in punishing their children. & Wahler, J.J. Klingbeil, K. A preliminaryevaluation of the Colorado RETHINK Parenting and Anger Management program.Child Abuse and Neglect, 23(4), 353-36 . & Sherrod, K.B. Ideally, the effectiveness of the developed program could be assessedby pretesting parents on standardized measures of: knowledge of childdevelopment, anger management skills, and disciplinary techniques. According to Siegel, Hill, Henderson, Ernst andBoat (1999), these include: developmental delay, borderline personalitydisorder, conduct disorder, antisocial personality disorder, posttraumaticstress disorder (PTSD), eating disorders, dissociative identity disorder,substance abuse, somatization disorder, suicide, depression, and self-mutilation.Risk Factors Howing, Wodarski, Kurtz and Gaudin (199 ) and the DHHS (1997) reportthat the following factors place children at risk for physical abuse: *Premature, ill, and low-birthweight infant *Older children are often more at risk for physical abuse *Difficult-to-manage child in the care of unskilled or dysfunctionalparents. Questions such as thesewould help to determine program effectiveness.Secondary Prevention Strategy When abuse, in fact, is known to occur, strategies must be put intoplace that terminate the behavior. Clinical monitoring of treatment course in childphysical abuse: psychometric characteristics and treatment comparisons.Child Abuse and Neglect, 2 (1), 23-43. Did parents feelthat there was a problem in this area? While child abuse affects children of all ages, the DHHS (1997)reports that about half of all abused and/or neglected children are under 7years of age. It is recommended byGreenwalt et. HRS-MC 81-1).Washington, D.C.: Health Resources and Service Administration, U.S. Thus, the developed program would remediate this problem ofproviding the child with two little counseling by extending the number ofsessions and mandating that at least half focus on working to remediate thetraumatic effects of the abuse on the child. (2 ). al (199 ) state thatmany times, physical abuse is a result of excessive discipline or physicalpunishment that is inappropriate for the child's age. Common characteristics have also been observed for victims of childabuse. & Dawkins, C.E. 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