Print version ISSN 0104-1169
Rev. Latino-Am. Enfermagem vol.14 no.4 Ribeirão Preto July/Aug. 2006
Violence against children and adolescents: a challenge in the daily work of the nursing team
Violencia contra niños y adolescentes: uno desafío en el cotidiano del equipo de enfermería
Simone AlgeriI; Luccas Melo de SouzaII
This article aims to reflect on various forms of violence against children and adolescents practiced in the family context, and the importance of professional nursing care in view of this phenomenon. We discuss possibilities of care and violence prevention as well as the problems violence causes to society. Violence is a social and historical problem, constructed in society, and needs to be adequately addressed in academic nursing education.
Descriptors: violence; domestic violence; child; adolescent; aggression; nursing; health education; family
Este estudio tiene como objetivo reflexionar sobre las formas de violencia contra niños y adolescentes practicados en la familia y la importancia de la atención de enfermería ante ese fenómeno. Para esto, discute las posibilidades de ayuda y de prevención de la violencia y los problemas que esta causa en la sociedad. Se concluye que la violencia es un problema social e histórico, construido en la sociedad, y que necesita ser contemplado en la formación académica de los enfermeros.
Descriptores: violencia; violencia domestica; niño; adolescente; agresión; enfermería; educación en salud; familia
Violence, in its different forms, is a phenomenon established through countless factors. It affects the family reality and constitutes a severe threat to life. According to the Brazilian National Council for Child and Adolescent Rights (CONANDA), each year, six and a half million children suffer some kind of domestic violence in this country. Eighteen million children are beaten up every day and 300 thousand children and adolescents are victims of incest(1). The violence problem is increasingly moving beyond the silence of the family sphere, becoming evident in society, mainly in hospital and educational institutions - and thus giving rise to daily news items in the media(2).
The Brazilian Federal Constitution determines that it is the obligation of the State, the Family and Society to defend the rights of children and adolescents. Unfortunately, this determination is insufficient to hide the sad Brazilian reality in which poverty, illiteracy and child work - as different forms of violence - impede that children's basic and elementary needs are preserved(3).
According to data by the Ministry of Health(4), violence and accidents together are the second cause of death in the general Brazilian mortality picture. In the group between 5 and 19 years of age, it is the first cause of death. This reveals the severity of this phenomenon, which ends up affecting the entire national territory. Moreover, it constitutes a large public health problem, mainly due to the feeling of insecurity caused in all social spheres and the financial costs it represents to the entire population(5).
Despite its gravity, however, we find the almost inexistence of violence studies from a public health perspective in Brazil. This justifies the need for research and reflections about the theme. Most existing publications come from the psychology area, denoting nursing professionals' lack of involvement with the violence phenomenon(6).
This demonstrates the pertinence of deeper reflections about the theme. This article aims to discuss the phenomenon of violence against children and adolescents, which is clearly present in the context of the nursing team, as it has been responsible for an increasing demand for public health care services. Based on a literature review, this study reflects on the 'violence problem' to support further analyses of nurses' involvement with this issue.
This literature review was theoretically based on books, theses, dissertations and journal articles, through a search in the LILACS and SCIELO databases and in the Automated Library System of the Federal University of Rio Grande do Sul, using the descriptors "violence or domestic violence or aggression or child or adolescent". Results were selected by reading the abstracts. If these addressed the study object, the full texts were analyzed. In total, we used 24 references to elaborate this article, which were organized in line with the interests of the intended discussion.
ANALYZING THE VIOLENCE PROBLEM
The history of violence against children and adolescents accompanies the human trajectory of social and, mainly, family relations(7). Some authors(8-9) affirm that this phenomenon has permeated world history since the most primitive recordings, being expressed by countless and different modalities, within cultural specificities. "Examples of childhood violence are present in History, in Mythology, Anthropology and in Religious Processes". However, it was only in the 20th century that the problem of violence against children and adolescents started to be studied, due to the new values attributed to the modern family(3).
Despite registration and notification problems and the omission demonstrated by many people's silence, statistics are starting to highlight violence against children and adolescents as a universal and endemic phenomenon, without any distinction of race, social class, sex or religion(10).
Two forms of violence against children and adolescents stand out, mutually distinguished by a series of characteristics. Intrafamily violence corresponds to any action or omission that impairs a child or adolescent's well-being, physical or psychological integrity or freedom and right for development. It can be committed at home or at another place by a family member, including persons who assume a parental function without blood bonds, and a relation of power towards the other person. Domestic violence, on the other hand, includes other group members, without a parental function, who live together in the domestic space, including employees, people who sporadically live at a family's home and aggregates(11).
According to literature(12), therapists working with the domestic violence issue have discovered that aggression against children and adolescents has the social function of maintaining families united and is used as a way to solve emotional problems. The same author declares that this violence modality has been an effective means of preserving collective emotional equilibrium.
The violence phenomenon is difficult to apprehend due to the level of subjectivity, polysemy and controversy it contains. However, its distinct forms and expressions can be analyzed(13). Moreover, there exists a clear relation between the globalization process and the production of new expressed forms of violence, such as organized crime, young people's activities in armed groups and domestic violence for example.
Violence against children and adolescents covers specific concepts of physical, psychological, sexual violence and negligence, which we will discuss next.
Physical violence is committed when a person, who sustains a power relation towards the child, causes or tries to cause non-accidental damage, through the use of physical force or some kind of weapon that can provoke - or not - external or internal injuries or both. According to more recent conceptions, repeated, non-severe punishment is also considered as physical violence(11).
Psychological violence "is evidenced as an adult's negative interference with the child and its social competence, constituting a pattern of abusive behavior. The most common forms are: rejecting, isolating, frightening, ignoring, corrupting and creating unreal or extreme expectations about the child or adolescent"(3).
Sexual violence is understood as any sexual act or game, whether in a hetero or homosexual relation, in which the aggressor has reached a more advanced psychosexual development stage than the child or adolescent, aimed at sexually stimulating him/her or using him/her as a means of reaching sexual satisfaction(14).
Negligence is explained as the fact that the family fails to cover a child or adolescent's physical and emotional needs. It occurs when the parents or responsibles neglect to feed, dress adequately, medicate or educate their children(3). Accidents can also be classified as a type of negligence, as they can be prevented and result for the responsibles' carelessness, lack of public investments and omission in traffic control, among others(7).
It is known that, in a ways, good or bad experiences are reflected in the adult personality. However, violence occurring silently within families and society, as if it were a banal phenomenon, remains surrounded with myths and taboos. Literature(15) mentions that families can be unprepared to understand, administer and tolerate their own conflicts and can become violent by tradition.
The cycle of violence against children and adolescents is thought to be directly related with the affective bond between parents and children. Many children feel threatened, neglected, abandoned and do not find reasons in their own environment to believe that they are important. Being constantly submitted to violence, these children learn that this is the only - inadequate - way to solve conflicts. This assertion is strengthened by the fact that children living in violent environments tend to believe that this is the only form of socialization, contributing to maintain the multigenerational character of violence(16).
In this context, families that propitiate violence determine a situation of severe lack of protection and vulnerability for the child or adolescent. This requires an analysis of the phenomenon in its social, political, economic and cultural complexity, and of the reciprocal relations among all of these aspects in the genesis of violence. According to researchers(17-18), the interpersonal relation that configures an abusive interaction pattern between parents and children was historically constructed by individuals who reveal the marks of their personal history in the social, economic, political and cultural context they are inserted in.
Silence due to the family pact is a cause of delay in care and undernotification of violence against children and adolescents(16). Hence, violence needs to be focused on from different angles as the construction of an adequate intervention will depend on the paradigm used to understand the reason why this phenomenon happens in each person's daily life. Nurse need to adopt a specialized approach to this problem, due to its constant presence in their professional practice.
Adopting the viewpoint that violence against children and adolescents is a form of relation established among family members - in its internal functioning or in social life itself - first, it needs to be denounced and denaturalized. According to literature(19), "the different forms of violence present in each of the relational groups that structure social life can be explained if we consider violence as an excessive and qualitatively distinctive act, which is verified in the exercise of each power relation present in social production relations. The idea of force, or coercion, supposes the production of damage to another individual or social group, whether belonging to a social class or category, to a gender or ethnic group, to an age or cultural group. Force, coercion and damage towards the other, as an excessive act that is present in power relations, both in the sovereign power's domination strategies and in micro networks of power among social groups, characterizes contemporary social violence".
NURSING AND THE VIOLENCE PROBLEM
Most public policies directed at violence against children and adolescents still have not analyzed how violent families produce violent youngsters. Children's exposure to domestic/family violence, responsible for the cycle of multigenerational violence, corresponds to the reproduction of violence in adolescence and adult age, in the family sphere as well as in society. In the hospital reality, this cycle becomes very evident, and efforts are made to interrupt it. Behind every child or adolescent submitted to violence, there is a family that needs help and care to continue. The destructuring of a whole family nucleus leads to severe consequences at the level of human relations and also generates a high social cost(5,15).
Nurses' actions are seen as a relational process of rehabilitating other persons. Hence, when aggressors (parents) spend time with the child who is hospitalized for violence, this allows them to get to know and interact with the nursing team. This opens up spaces for the construction of a help relation that seeks, at all times, to create awareness about the importance of a new way of relating to the child, establishing healthy living and the opportunity to break the cycle of multigenerational violence.
The incessant search to understand the facts becomes a permanent challenge for nurses with a view to a safe intervention. Multidisciplinary teamwork is essential, as an early diagnosis of the situation allows for the elaboration of adequate care plans. The group's participation and supervision are fundamental since, besides trying to exceed the limits of professional training and experience, this also provides for a space to share impressions, anxiety, advances and frustrations(20).
What needs to be done to face the problem of violence against children and adolescents is to take a stand: take the first step, the beginning that challenges the denial of this problem by society and implies the definition of priorities and the establishment of immediate protection processes for the child/adolescent. However, "the understanding of the phenomenon gains depth and starts to focus not only on the aggressor-victim pair, but also on the social system that repeats violence, to the extent of acknowledging that not only the family sphere, but also the community environment, social relations in school, the educational culture practiced in society, the parents' life history and the subjects' economic and social conditions make them more vulnerable to suffer or provoke abuse"(21). Violence is a very polemic issue, as it interferes with family standards and dynamics, involving corrections and separations. However, complaint, debates and reflections are paramount to fight this problem.
Thus, nurses need to have scientific knowledge about the 'violence problem', in order to comply with their professional care responsibility. Moreover, they need to be legally and morally committed as citizens/professionals, officially informing pertinent bodies - like the Guardianship Council and the Public Prosecution Service - about suspected cases of violence against children and adolescents. However, this precedes the task of facing and coping with their own feelings and emotions about adults who commit some kind of violence, revealing ethical and moral conflicts that need to be explored throughout their training - at academic level, in subjects about this theme; and in their professional environment, through permanent education.
Academic nursing formation insufficiently considers the violence problem in subjects about children, adolescents and families. One of the main reasons for the lack of this approach in the academy is the fact that domestic/intrafamily violence is a health problem/condition that does not contain physiopathological concepts and is not explicitly included in the International Classification of Diseases - ICD-10(22). Including this theme in the curriculum would prepare nurses to diagnose this severe collective health problem, which is a relevant factor for care intervention and prevention of violence at an early stage. Moreover, this would enable nurses to face the violence phenomenon through 'other eyes', adopting a holistic approach instead of exclusively focusing their care on the physical consequences provoked by the act of violence against the child or adolescent.
These reflections are in line with the Global Report on Violence and Health(23), which points towards the importance of professionals' decisive action towards the daily reality of violence against children and adolescents, in order to promote the protection and integral development of the human being who is taken cared of.
Therefore, it is vital for public policies not to be directed exclusive at the children and adolescents, but to include the main nucleus they are inserted in: the family.
Nursing actions involving families are fundamental, mainly at the three prevention levels: primary, secondary and tertiary. At the primary prevention level, strategies need to be directed at the whole population, with a view to reducing the incidence and prevalence of violence cases. Primary prevention strategies can be developed through prenatal care programs, promoting mothers' rooming-in with their babies, encouraging fathers' participation in the delivery room, reinforcing attitudes that strengthen the primary bond between children and families. In this context, nurses' actions in the Basic Health Network also stand out, where they should act by holding debate groups with parents, at Basic Health Units as well as kindergartens. Besides caregivers, nurses should also assume the role of educators in their care activity, showing parents the ideology of protecting the rights of children and adolescents at all times.
In secondary prevention, nurses should identify families with a potential risk of violence, so as to verify the existence of situational crises, that is, elements that could lead to a modality of violence. There is a need to assess, for example - during the prenatal period, pediatric appointments, among others - families with a risk for abusive behavior, proposing alternative solutions, like in the case of parents in a situation of chemical dependence, advising and referring them to specialized treatment. Another alternative is to emphasize, as early as the first contacts, the importance of positive discipline, imposing limits for the child's healthy development, which is different from strictness or omission. Moreover, nurses should visit families' homes to deliver specific care to vulnerable groups and also to promote health education.
In tertiary prevention, nurses act when a situation of violence against children and adolescents has already occurred and one of the goals, besides treatment, is to prevent its recurrence. When the situation of violence is identified, it is important for these professionals to maintain a solidary attitude towards the child and his/her family, offering support to solve the problem instead of punishment, and providing alternative strategies to solve difficulties in family relations(16).
No matter what place nurses are active in, fighting the phenomenon of violence against children and adolescents, we emphasize the importance of articulation, involving the academy and health services, direct care professionals and faculty/academics. The exchange of experiences among them - at the level of research as well as care - can lead to improvements in nursing professionals' actions towards children/adolescents who are victims of violence.
The global character of the violence phenomenon needs to be present in discussions about public policies, turning into a constant challenge for the nursing team(7). Nurses need to act as facilitators among the child/adolescent, aggressors and health teams. Therefore, it is not enough just to "have, set up or train teams and people but, mainly, to study the range of the theme with scientific rigor"(2).
It is important for nursing professionals to turn the hospital into a less hostile, less aggressive and more welcoming environment through their actions. Therefore, they should include playful aspects in their care actions, which meet with the infant world, seeking to minimize the pain and suffering caused by violence. Interesting activities could cover, for example: telling children's stories, performing drama sessions with care material (syringes and equipments), besides holding group creativity workshops, using clay and paint, among other possibilities. At the same time, through the socialization and expression of feelings and problems, parents will have the chance to visualize, by means of the nurses' attitudes, adequate actions that can allow for another model of relationship and interaction between themselves and their children.
In the Basic Health Network, nursing professionals also play a fundamental role in coping with violence against children and adolescents, as this care level favors the early detection of these cases. However, for this to occur, there is an urgent need to change routine approaches used at these services, which tend towards a care view based on healing practices that are especially based on the observation of signs and symptoms of clinical pictures. In the initial stage, nurses should provide a decisive contribution in the identification of events that deserve immediate or indirect intervention, revealing reliable reasoning processes. In this perspective, one possible idea could be the inclusion of questions about violent events in nursing consultations, as these could attract professionals' attention to the need to act on this question with the family(24).
In conclusion, nursing professionals need to get involved in the quality improvement of health services, in order to contribute to the construction of a more righteous, democratic and solidary society. This would recover their wide-ranging and serious social, political and moral commitment to their professional praxis. No matter the area he/she is active in, in a way, each professional is responsible for children and adolescents who are facing a situation of violence and are entitled to the unalienable right to life. It is everyone's duty to create adequate conditions for this to occur. This study reveals that the first step needed is the deepening and expanding of discussions about violence, so that nurses use the obtained scientific knowledge to urgently face the challenge of detecting, notifying, taking care, minimizing and preventing situations of violence against children and adolescents.
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Recebido em: 26.9.2005
Aprovado em: 9.2.2006