Health care professionals' approaches to address family violence against children and teenagers

Abstracts

OBJETIVO: Compreender o modo como os profissionais de saúde abordam as situações envolvidas na violência intrafamiliar contra a criança e o adolescente. MÉTODOS: Pesquisa de natureza qualitativo, na modalidade de estudo de caso, realizado com 30 profissionais de saúde. RESULTADOS: Os profissionais mostraram-se preocupados com a falta de resolução dos problemas. Revelaram que as medidas empreendidas priorizam a punição em lugar do atendimento e que a estrutura de trabalho não lhes permitia expor seus sentimentos e reações e com eles lidar. O modo de abordar as famílias que já vivenciaram violência pode configurar um ato violento para com estas. CONCLUSÃO: A maneira como é realizada a maioria das abordagens em casos de violência contra a criança e o adolescente reflete a falta de integração entre os profissionais e os diversos setores.

Violência doméstica; Assistência à saúde; Enfermagem pediátrica; Saúde da família; Saúde pública

ORIGINAL ARTICLE

Profesionales de salud y violencia intrafamiliar contra el niño y el adolescente

Cristina Brandt Nunes^I; Cynthia Andersen Sarti^II; Conceição Vieira da Silva Ohara^III

^IAssociate Professor at Universidade Federal de Mato Grosso do Sul - UFMS - Campo Grande (MS), Brazil

^IIFull Professor at Universidade Federal de São Paulo - UNIFESP - Campus Guarulhos(SP), Brazil

^IIIAssociate Professor at Universidade Federal de São Paulo UNIFESP - São Paulo (SP), Brazil

Corresponding Author

ABSTRACT

OBJECTIVES: To understand how heath care professionals approach family violence against children and teenagers.

METHODS: This was a qualitative case study with 30 health care professionals.

RESULTS: Health care professionals were concerned with the lack of successful family problems resolution. Measures used by health care professionals emphasized punitive actions instead of caring behaviors. The characteristics of the job did not allow of the health care professionals to express their feelings and reactions and to know how to successfully address family violence. Health care professionals' approaches to address violence with families who already experienced violence may also become violent acts against those families.

CONCLUSION: Approaches used to address family violence against children and teenagers reflect a lack of integration among the several categories of health care professionals and health care services.

Keywords: Domestic violence; Healthcare; Pediatric nursing; Family health; Public health

RESUMEN

OBJETIVO: Comprender el modo cómo los profesionales de salud abordan las situaciones relacionadas a la violencia intrafamiliar contra el niño y el adolescente.

MÉTODOS: Se trata de una investigación de naturaleza cualitativa, de tipo estudio de caso, realizado con 30 profesionales de salud.

RESULTADOS: Los profesionales se mostraron preocupados con la falta de resolución de los problemas. Revelaron que las medidas emprendidas priorizan la punición en lugar de la atención y que la estructura de trabajo no les permitía exponer sus sentimientos y reacciones y lidiar con ellos. El modo de abordar a las familias que ya vivenciaron violencia puede configurar un acto violento para con éstas.

CONCLUSIÓN: La manera cómo se realiza la mayoría de las abordajes en casos de violencia contra el niño y el adolescente refleja la falta de integración entre los profesionales y los diversos sectores.

Descriptores: Violencia doméstica; Asistencia a la salud; Enfermería pediátrica; Salud de la familia; Salud pública

INTRODUCTION

Childhood and adolescence are a period where vulnerability to harms to health and to psychosocial and economic factors is worsened. In a situation of violence, the family is no longer a reference of education and protection for children and adolescents since family ties are also violent⁽¹⁾.

The analysis of intra-family violence cannot be restricted to the logic of attacker and victim since these are not fixed positions but part of a relational mechanism where actors can change places⁽²⁾. Violence situation demands a type of care that considers relational aspects and their context. To approach it, health professionals need to deal with different types of facts and feelings which they are not ready to or prepared for. On one hand, they want to move away from the problem but on the other hand, there is a moral duty to help these families⁽¹⁾.

The present study aimed to understand how these health professionals approach the situations of intra-family violence against children and adolescents. We looked for subsidies to understand how the problem of children and adolescents victims of violence usually at home and by people who are part of their lives is presented to health professionals.

METHODS

Qualitative reference was adopted because we can assess human experience in the social context in which people work, without introducing changes in this environment. Case study, the method of choice, adjusted to Social Sciences enables to encompass not only one individual but an organization or community⁽³⁾. Investigation occurs by observing human behavior in a group, considering individuality and behaviors and interpersonal relations⁽⁴⁾.

The research subjects were 30 professionals (nurses, dentists, physicians, social assistants, unit managers, nursing assistants, dental assistants and community health agent) part of four teams from Estratégia de Saúde da Família (Family Health Strategy) in Campo Grande, MS. Research instruments were participative observation (to know professionals' dynamic with children, adolescents and their families and their interactions), the interview (with questions and strategies gradually designed according to the situations presented) and the document consultation at the Family Health Basic Unit, in the South Guardianship Council and the Municipal Public Health Secretariat. The research project has been approved by the Research Ethics Committee at Universidade Federal de São Paulo (protocol # 1587/2003).

Data analysis consisted in reading reports, field diaries and documents. By repeating questions, data were grouped into themes and later they became thematic categories which were the guiding axis for analysis.

RESULTS

Data convergence referring the different ways professionals deal with violence against children and adolescents will be presented into two main thematic categories: Finding hard to define the problem and Disarticulation of the service network.

Finding hard to define the problem

Obstacles found to deal with violence situation against children and adolescents, such as unpreparedness and lack of support from institutions concern health professionals surveyed, leading to a feeling of powerlessness and frustration.

F's case is an example. The child lives under conditions that are not proper for her growth and development. Professionals tried to change this picture by taking some actions. Due to the precariousness of housing, they even bought the family a sink and a toilet. In their constant visits, professionals have given parents guidance on health actions (body hygiene, house cleaning, vaccination); however, they do not perform these actions. The child had her school enrollment cancelled because she was frequently absent. The reason given by parents for their child's absence is lack of money for the bus fee because they had lost their free pass. Eve though they were given bus tickets, they did not continue with specialized follow-up. When her house was visited, the child was pale, thin, had problems walking and only mumbled. The impression we had is that she stayed on the crib for too long. A nurse reported: "I think the situation is difficult to solve [...]. I have to try to help, finding a way without getting to much involved". A health community agent did not consider herself trained to deal with cases that go beyond health because she was not sure about the best management: "[...] I believe it is not the health agents' role, because it is a social problem and we do not have the mechanisms to deal with it [...]".

L's case, a child who did not receive the necessary support, impressed a dentist. The wooden house was falling apart. There was mud in the patio and a very skinny dog. C., the father, had been unemployed for a long time and was an alcoholic. S., the mother, had wounds on her feet. There was no food on the house, everybody looked hungry. L. was thin and had scabies. Pictures such as this one are depressing: "The team suffers a lot when we see this! Because for us, we have kids and we do everything for our family, we get shocked! The team mobilized itself to try to solve the problem. The strategy adopted was to "adopt" the family. The community health agent scheduled medical, nursing and dental appointments so that S. would not have to wait in the line for an appointment. Even with the scheduling they did not attend the appointments, they always mentioned setbacks and sometimes they got annoyed with the questions. On the professionals' point of view, she was not interested in changing the situation. For house cleaning, professionals requested a partnership with Pastoral da Criança (Social Action Organ of CNBB). Additionally, L. started to receive milk powder that was given in the unit. The physician provided fruits and vegetables to the family, after the visit performed by Psychology students, followed-up by nurses, one of them started to take soup to the family. Despite the contributions received, professionals did not observe a significant response. For the nurse, the situation worsened to such extent that if the child did not leave the house "she would die". The solution found was to take the baby to the nursing assistant J.'s house.

A case of sexual violence occurred with a 3-year-old child that lived with her mother. According to the mother and neighbors, the child was molested by a neighbor. The medical examination at the Institute of Forensic Medicine did not show physical evidences of sexual abuse to the child. For further investigation, the community health agent tried to approach the issue with the mother, leaving her at ease to report the events. On the second home visit, she realized the mother did not want to talk about the issue. Concerned with the facts, she talked to the team's physician: "So I told her what had happened. But she never had the time to visit them". For the agent, there were never any actions taken to solve the problem or an effective approach involving the child and her family. She felt the need to disclose the situation to other people, but the secrecy involving the events did not allow her to do that. She felt frustrated by what had happened because her actions did not have the desired effect.

When professionals become aware of a case, they may have questions regarding the actions they should take for reporting. A nursing assistant reported a situation of a health community agent that was threatened by a child's father so that she wouldn't charge him, and was being pressured by neighbors to take a position: "The child is a year and a half. The father beats the mother up, if the child cries, he beats her up too. The neighbors tell us, health agents, to do something [...]. These days, the father parked his motorcycle in front of the health agent's house. He stared at her, trying to frighten her".

In another situation, a mother did not want to receive the visit of the health community agent any longer because she believed she would report her to the Guardianship Council: "[...] the mother beat her eldest son up very badly. The boy would go to houses asking: 'Can I live with you? [...] the first rumor was that I had reported the mother. But I had not! Somebody called the Guardianship Council and the mother accused me". The agent considers that being seen as an informant may hinder her work at the community.

Another report showed the questions a physician had regarding the real benefits reporting had in children's life: "Many times it is difficult to know what to do without harming children. When you report and it is true, they take the child away from home. It is also an aggression to take them away from their family! So, it is necessary to have a criterion, and to fight to give children a better support! [...] Why should I interfere, or comment if I can worsen the situation?"

These events show the lack of structured work with strategies that enable professionals to be partner of the families, even in conflicting situations, as the one created by the charge.

Disarticulation of the service network

The way most approaches are carried out in cases involving violence against children and adolescents reflects the lack of integration between professionals and the several sectors that should deal with these issues.

A social worker and unit manager reported that the team supported the family for a long time, with guidelines on the boy's health care, providing material resources for the house infrastructure and enrollment of the child in a special school. She adds: "We report to the Guardianship Council on what is going on with the family. Sometimes we have to insist for them to come. The process is slow. I did not see many changes".

A physician reported the way the team dealt with the situation after neighbors reported three children of a family suffered physical abuse. Initially, families refused the work of professionals: "The team went to her house and talked. There were three children, a newborn, a one-year-old girl and a three-year-old girl. The father [step father] beat them up because they cried at night. At first, they did not accept our presence". After the Guardianship Council visited them, there was relative decrease in physical abuse, according to the physician this was probably due to stepfather's fear of being punished, rather than a change in attitude.

For some professionals surveyed, there is lack of integrated work on the team itself. The cases involving some type of violence against children or adolescents are not always known by most people. For a social worker, this may be related to fear of community health agents to suffer retaliation by the reported people, since they live in the same urban space. The fragility experienced by community health agents is related with lack of structure which enables them to work more safely: "[...] domestic violence is disguised. Neighbors avoid making comments, and when they do make comments to health agents, they do it very discreetly. This should be done in such a way that they would not feel so afraid of taking a position".

A work approach where professionals give priority to suspected or confirmed cases is also lacking. The actions taken to fight situations involving violence run the risk of being postponed as explained by a nursing assistant: "I told the health agent to communicate to social worker on this case. But he is on vacations. And on these fifteen days that he is away, will the child continue to be assaulted? I told the nurse but she did not do anything".

In the daily activities, sometimes there is lack of concern for children and their families' real problems, because of the pre-established rules. Several events confirm this fact, such as the one that occurred with V. and her daughter E., who was physically abused by her father. The community health agent, when she heard about this event - and also that "the mother had offered water and sugar for the children and that everybody was starving at the house because the father was unemployed" -, she tried to enroll the family in programs such as Programa do Bebê (Baby Program), so that they could receive powder milk. However, in the Basic Health Unit, the nursing assistant taking care of the mother told her: "I enroll people at the milk program. First of all, I'd like to say that I cannot enroll her without her birth record number [...]. How come you don't have the birth certificate! I am sorry! There is nothing I can do [...]". The mother folded the paper with the requirement without getting enrolled at the Program. Without a word, she left.

Professionals get emotionally involved with violence situations against children and adolescents easily.

A physician expressed her difficulty in dealing with lack of efficiency in solving some situations due to the absence of partnerships with departments that are external to the Unit: "It is very delicate and very hard, because this involves our emotional side. [...] I get tired because I needed a greater support. [...] There should be a formed structure where we could request support and that worked with us! [...] It is not like that, it's not having the Council coming, punishing and saying: 'If you don't do that, the child will be taken away' ".

DISCUSSION

The difficulty to define the problem is because professionals are not ready to deal with facts that involve violence against children and adolescents and the inability to find a clear and direct response to the situation leading to a feeling of powerlessness. It is difficult to establish families' lack of economic conditions to provide the necessary care.

To approach the issue of negligence towards children as a type of "ill-treatment" is a complex and delicate task, because it has to do with looking at the others and it can show different types of prejudice. What is considered as "negligence" can actually be a different type of care. For that reason, to deal with the situation requires interdisciplinary resources⁽⁵⁾, since some professionals can interpret the social aspects involved with violence with mechanical linearity.

When this is done, professionals try to medicate violence because of their biomedical education which consists in looking for defined diseases so they can prescribe some kind of treatment. They find it harder to deal with problems that are more connected with the social side such as situations involving violence. They are more used to traditional interventions of treating diseases rather than working with preventive actions and approaches giving priority to health promotion⁽⁶⁾.

The commitment of some professionals to provide food and financial support to the family and to take care of children's health (to such extent that one of them was adopted by the nursing assistant) seems to result in a feeling of merciful compassion.

In the routine of care, professionals surveyed tend to deal with the public space structuring it so that it is similar to the family environment. This shows two categories that are opposed in the Brazilian society and that represent "the house and the street". So, "to be home" or "to feel at home" concerns the situations where relationships are ideally harmonious and dispute should be avoided⁽⁷⁾. The street is the place where individuals are anonymous and their needs are not met. Under certain circumstances there is the trend to encompass the street on the house, recreating the family environment in the public space. This occurs when professionals, because of the way the service is structured, find it difficult to treat violence in the public space and take the problem home.

This can also show an inadequate type of care since taking care of the other can mean to anticipate the other, taking up the responsibility of people to take care of themselves. This may make people subdued in a silent way⁽⁸⁾.

In most cases, ill-treatment, especially sexual abuse, cannot be demonstrated because there are no evident lesions^(9-10).

Identifying abuse is also hindered because families know the abusers many of the times and usually they are people trusted by the families with authority and free access to children⁽⁹⁾. These facts make professionals fragile because of the lack of a work plan.

The facts call attention to the need for directing the look for workers who perform this care, in order to give support to individuals taking care of victims of violence. Dealing with sexual violence can lead to an intense emotional load that should be taken into account by public policies to face violence⁽¹¹⁾.

The dead-lock experienced by professionals regarding charges is made stronger because they are close to these families, especially community health agents who live in the same district.

Health professionals are resistant to make a notification. This resistance is related with negative experiences they had after charges were made, they were persecuted by families of the victims because they did not have protection or institutional support to their initiative^(12-13).

One of the actions frequently taken by health professionals and law operators in the case of children being victims of ill-treatment is to take them away from family life, transferring them to orphanages or to other families. Although these measures offer protection against new episodes, the trauma experienced does not end when these children are taken away from their homes. There is the risk of victims become part of a context where they can experience new negative events⁽¹⁴⁾.

In face of violence situations, health professional may feel de immobility that, if on one hand it leads to anguish, on the other hand it can make them used to limitations to their practice, and they run the risk of not speaking up about situations that could solve or minimize the problem⁽¹⁵⁾.

The form most violence cases against children and adolescents are approached reflect the disarticulation of service network.

In the cases where professionals and Guardianship Council were approached, there was no follow-up of problems in the long run. To follow-up cases could be a type of support for families dealing with difficulties in the relationship with children, which could make it easier for problem solving. However, in the management approached, there was predominance of neglect or severe punishment. Another aspect highlighted was the desire to take children away from the family because interventions did not work, this can be as harmful as the violence itself, because children can understand they are not wanted by families⁽¹⁶⁾.

The lack of visibility of solutions for cases involving violence was seen in a study carried out with professionals on the approach of ill-treatment against children and adolescents in the public health service⁽¹⁷⁾, which revealed that cases referred to Guardianship Council are usually not solved. Notifications are commonly not responded and when they are answered, it takes too long. The cases are frequently not followed-up and this makes a partnership with the Guardianship Council difficult.

Another aspect pointed out is that professionals, to maintain an assumed order, use their power to discipline families that do not follow the rules, but this makes their living conditions even worse - therefore it is essential that the care provided to families experiencing violence situations is not more violent than the violence it is trying to fight.

Health professionals have to be careful so that their services are not an institutional violence, which leads to a trivialization of life and disrespect towards the other, when they need the most to be heard, welcomed and understood⁽¹³⁾.

An important aspect of the approach of situations where there is violence against children and adolescents is that most preventive strategies focus on victims and assaulters, rather than on the complex problems that are part of the violence dynamics. The effort and prevention policies are geared to children and adolescents and their guardians, taking into account the environment they live in⁽¹⁸⁾.

The reports made by professionals show their need to have a work structure where they can express and deal with the feeling and reactions triggered by the events involving violence against children and adolescents.

FINAL CONSIDERATIONS

The way most approaches are carried out in cases of violence against children and adolescents reflect the lack of integration between professionals and the several sectors that should deal with these issues.

Developing a proper care approach for children, adolescents and their families where there is intra-family violence is essential and it should encompass the design of a proper structure that can be flexibly adjusted. This care requires a multiprofessional team and a multi-disciplinary approach that goes beyond the biological dimension of care. Additionally, a social support network is necessary with different institutions and sectors and that is not restricted to the health sector, favoring a partnership with the community.

Violence is a serious social problem that causes health hazards. Because of its contextual and relational aspect, health professionals need to take into account in the approach of cases, that in the process of violence against children and adolescents not only victims and assaulters are present but also the other family members and the place where violence occurs.

Dealing with this multiple relations is still complex for health professionals. Therefore, health action planning should have strategies geared to train professionals to approach issues involving violence against children and adolescents.

In the education of professionals, it is timely that both in the field of Health and Social Sciences the teaching and learning process present contents referring to violence against children and adolescents. Therefore, professionals must understand since university that this phenomenon is not limited to physiopathologic aspects and that there is a relational dynamics involved in it.

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Health care professionals' approaches to address family violence against children and teenagers

Publication Dates

• Publication in this collection
  10 Mar 2010
• Date of issue
  2009