Responding to the September 8, 2006 article “Forensic Nursing Definition”

Besides signs of physical abuse and malnutrition one would do well to be aware of any signs of emotional abuse in children. This is of particular importance since emotional abuse can often be a precursor of physical abuse and its detection can help prevent further abuse before it starts. Of course emotional abuse is much more difficult to detect especially in children.

Part of the reason that emotional abuse goes undetected in children is that children laugh and play a certain percent of time each day even when they are suffering from depression. Due to their ability to put difficulties aside for periods of time much better than adults, children also manifest depression differently than adults. A child may not show the flat affect typical of adult victims of abuse until the abuse has reached an extreme. Yet another complicating issue is that given the child’s view of the world, abuse from one adult tends to make them suspicious and less trusting of all adults.

Therefore the first step in assessing a child should be to establish rapport. This is done primarily by showing respect for the child, her position and her opinion. Sitting or stooping so that one’s face is at the level of the child’s face, greeting the child politely just as one would an adult, addressing questions directly to the child and listening attentively while smiling and making appropriate eye contact is a good beginning. Asking the child’s permission before touching her and taking her answers and opinions seriously improves rapport. Avoid correcting the child’s grammar or word usage – instead listen for meaning and content. Correcting the child establishes a “one up” relationship, which can destroy rapport and trust. The same applies to correcting, or questioning a child’s statements even if they may seem fantastic or are obviously untrue. Young children do not readily separate fantasy and reality and may even use a story of an imaginary playmate or imaginary event to test the adult for trust ability before revealing more important closely guarded information.

Depression in a child manifests differently than in an adult. A child may glance fearfully or nervously at the parent or guardian before responding to questions. He may change his response based on a look from the parent. He may experience stomach aches, headaches, or exhaustion more frequently than normal. She may sleep more than normal, have an increase or decrease in appetite. A naturally slender child who begins to show signs of being overweight may be suffering from emotional abuse. Check the medical history for height and weight. A depressed or abused child may have trouble in school or be teased by peers and may thus dislike school in general without sighting specifics as to why. Asking questions about school or friends can help reveal some of these patterns.

While these signs may yet be considered too subtle to warrant legal action the nurse or attending physician could recommend a qualified children’s counselor or other intervention and support. Making a note of findings and concerns in the patient’s medical charts may well aid early detection should the abuse escalate. Offering parenting support services may also help circumvent further escalation. Such action can well save children from physical and sexual abuse before it starts.

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