Research Topics: Sample Critical Discussion

A Critical Discussion on ways in which counselling theories can inform and support a healthcare/social care practitioner’s intervention strategies

src=”http://pagead2.googlesyndication.com/pagead/show_ads.js”>   INTRODUCTION           Ideally, it can be that counselling theories do inform and support healthcare practitioners in such intervention and strategy the practitioner wishes to use and apply effectively within the healthcare setting such as for example, those that relates to health promotion activities as the health practitioner is amiably expected to improve community health such as through encouraging people to commence at the same time develop certain health promoting behaviors and to avoid cases of health damaging behaviors. The counseling approaches in action do provide healthcare practitioners simple yet effective processes and ways to improve their craft in such field they are involved with and thus allowing healthcare practitioners to think as well as plan out precisely of the things they are required to do in a specific situation for instance, within such health consultation sessions, the approaches would probably help these practitioners to concentrate on a particular therapy that can be relevant and helpful to such case situation as deemed possible. Thus, making them successful in providing appropriate health interventions as needed and provide ways to make such changes or adjustments in systematic and organized manner.     DISCUSSION           There can be such suggestions that perhaps can be possibly missing for several health practitioners that may involve such specific skills pointing to such approaches as the counselling ways will then knowledge that is required to systematize such counselling theories and models like, in certain areas of health promotion for example, which amicably measure the healthcare practitioners’ ability to apply and execute such theory for a particular health intervention. Aside, it can be such concern, however, that the practitioners may recognize and consider such theory like, motivational theory to be helpful in the earlier stages of the process. There can also be established health promotion theories and models as such fact that practitioners would perceive that such approach will be utilized effectively across such range of therapeutic actions and behavior within variety of health care settings and the intuitive logic of useful elements found within each theory’s level of effectiveness upon usage and realization of goals as practitioners learn to assess and evaluate the process into such controlled situation. The health care practitioner’s understanding of the counselling theories is imperative as it do enable them to be sure that they have certain share, at the same time more deliberate and accurate, understanding of such theoretical approaches from within such functionality.             The healthcare practitioner adheres to such ideals that the usage of such approaches is equally important and crucial in increasing their knowledge and practical skills needed in order for them to be reliable in assessing and interpreting such outcomes such as those pointing towards health care examination and tests in lieu to psychological and clinical assumptions and that, it can be that by measuring there will be determination of certain theory extent to which the approaches are appropriately used and foster the degree of professionalism of health care practitioners. Moreover, certain information could then be used to develop `best practice’ guidelines for counselling process, including such comprehensive explanation of the theory that is understandable to the practitioner and his clients within series of theory applications to demonstrate how these can be applied to diverse health care interventions as duly integrated by the practitioner.                         Furthermore, one good example pointing to such ways could be the use of the intervention mapping process (Cited from, Bartholomew et al., 2001) in which there is providing of useful tool for health care practitioners in application of such theory into an integrated health program and its design. Thus, in the Intervention Mapping, the practitioner starts by identifying the question to be answered and brainstorming certain list of potential determinants of the problem. It is at this stage that the practitioner, armed with the list of determinants and related constructs, returns to the literature to identify relevant theoretical concepts. In this way the practitioner can use the theoretical constructs to answer the question posed and identify additional constructs that may increase the explanatory power of the proposed answers. (Cited from, Bartholomew et al., 2001) In order to increase the appropriate use of theory in health care practice the practitioner will need to use several techniques and strategies as applied upon changing the behavior of those involved in intervention process from within ideal counselling approaches for a valid indication of health care programs and activities respectively.                   Practitioners being also professionals in most settings find that they provide good counseling therapy in accordance with their education, training as desired amiably for such itemized needs of their clients. In current usage, the terms tend to be used arguably will be depending on the service setting. Thus, during counseling sessions, it can be that the health care practitioner applies his or her expertise to benefit each recipient, directing them to use information in such way that serves best in everyday life. Then, the practitioner’s skills should be supported by theoretical models found with the aspects of such functionality underlying better ways that are working well in informing good health care practice as needed as possible. (Cited from, Bartholomew et al., 2001) Although the practitioner needs some advanced knowledge in the field for specific health and or mental related condition, one of the goal can be, is to offer generic approach to lifestyle behavior change directed towards unfamiliar patterns of behavior for instance, there ways that is associated with increased risk of health issues and problems faced by the practitioner.                     However, health care practitioners who are open to certain integrative perspective will find that several theories play crucial role in their personal counseling approach. Believing that every theory has its unique contributions and its own domain of expertise. By accepting that each theory has strengths and weaknesses and can be peculiar from the others, practitioners have some basis to begin developing theory that fits for them. It is important to emphasize that unless practitioners have an accurate, as well as in-depth knowledge of theories, they cannot formulate true synthesis. Simply put this into consideration, practitioners cannot integrate what they do not know (Cited from, Norcross and Newman, 1992). The challenge really is, for practitioners to think and practice integratively and critically through developing integrative perspective into lifelong endeavor that is validated and refined with ample professional experience.               CONCLUSION           In conclusion, one health care practitioner has frequent opportunities to help patients clarify issues and alter adverse behavior patterns because of ample understanding and skills towards such counselling approaches from within their area. The formulations of ideal framework within counseling notions do possibly clarify core principle and tasks for the health practitioners that amiably represent properly the needed requirements for successful counseling. Therefore, some situations respond to brief advice, others require several repeated counseling sessions utilizing concepts from behavioral theory, and certain ones need referral to structured counseling program that employs longer timeframe and allows for the opportunity to use range of method assisting healthcare practitioners to successfully reach their clients. The practitioners would do well to consider their own personal style in the process of developing their integrative approach.                       The art of integrative counseling implies that there are no prefabricated models that fit any practitioner perfectly. Instead, the challenge is to customize counseling approach that is tailored for each practitioner. Then, as an outcome counselling theories do inform that the practitioners should give careful consideration to limitations of their training and experience and work within these limits, taking advantage of available professional support. If work with clients requires the provision of additional services operating in parallel with counselling, the availability of such services ought to be taken into account, as their absence may constitute significant limitation. Also, it informs practitioners to ensure that services delivered have to be base on the client’s clear consent. The increasing availability of counselling approaches means that most practitioners have other practitioners working in their locality from within multidisciplinary teams respectively thus, increasing better insights as well as expertise in health service oriented relationships as the practitioners have ample responsibility within themselves to ensure that their work does not become detrimental to their well-being by ensuring safe work environment and duly look for appropriate professional support and services to maintain high knowledge and understanding of certain skills.     REFERENCE Bartholomew, L.K., Parcel, G.S., Kok, G. and Gottlieb, N.H. (2001), “Intervention Mapping”, Mayfield, Mountain View, CA   Norcross, J. C., & Newman, C. F. (1992), “Psychotherapy integration: Setting the context”. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 3–45). New York: Basic Books   Credit:ivythesis.typepad.com

A Critical Discussion on ways in which counselling theories can inform and support a healthcare/social care practitioner’s intervention strategies

src=”http://pagead2.googlesyndication.com/pagead/show_ads.js”> INTRODUCTION Ideally, it can be that counselling theori...

Sample Critical Discussion about a company’s Leadership and problems of the board that will be useful in the assessment of the situation

Unit 1 – DB Discussion on Consultation Notes             Given the presented situation of Dr. Jean Paul Dupres, I was able to observe and list down the several problems of the board that will be useful in the assessment of the situation. First problem of the board is the ineffective leadership of Ken Martin, on being not able to coordinate the board members. Although he fills the gap of becoming a Chief Financial Officer of CFO and reports to the president, his lack of leadership skills causes him to not be recognized as a formal member of the board. This is maybe due also to the fact that he is only a representative, doing favors for James Haworth. Second problem is the need for a Chief Financial Officer to coordinate and direct the divisional finance executives and create a unified financial operation. Third problem is the needs of the company for a consultant, who will help Ken Martin, coordinate team efforts of the board. Fourth problem is the problem with teamwork in all functioning areas, which may affect reporting to a newly appointed CFO in the future. Fifth problem is the resolving conflicts regarding Chairmanship. Lastly, Dr. Jean Paul Dupres’ problem, regarding his being both the company’s CFO and board chairperson. He believes that his responsibilities caused great conflict and confusion at all levels of the organization, which has no effects on the improvement of Ken’s leadership, and even weakens the functioning of the Executive Group (“Career Education Corporation Online”, 2006, attachment).             With these problems, I was able to efficiently identify the strengths and weaknesses of the situation. Strengths include the Executive Team’s desire for improvement, which is evident through their intentions of enhancing the skills of their members. Another is the loyalty of the board members to the company, which shows their desire for improvement and development of the members. Third is the board’s recognition of Ken’s potential and the need for his improvement. This strength shows the initiative of the board members to give room for Ken’s improvement, and lastly is the generosity of Dr. Dupres, who is willing to give him a second chance to improve his performance.             Weaknesses of the situation include Ken’s lack of leadership skills, the functioning team’s lack of coordination and cooperation, the dilemma with individual work and performance of the employees, the Executive Group’s lack of unity, mishandling of resolving conflicts regarding Chairmanship, and the need for Ken’s coaching that would result to his growth and improvement.             In identifying the strengths and weaknesses of the situation, it would be easy for me to raise suggestions and make negotiations. First suggestion or negotiation is for Dr. Dupres to continually assess the performance and skills of Ken, and even be the person to coach him. Ken’s coaching must be started immediately, to efficiently and effectively delineate the tasks and responsibilities of the members of the board. Dr. Dupres can also ask John Babcock or James McDermott to coach Ken. In addition, the board must be able to continually evaluate the skills, performance and qualities of Ken, if he is more suitable to become the company’s CEO or CFO. His training or coaching must include his knowledge and application of the different styles of leadership, namely, Coercive, Authoritative, Affiliative, Democratic, Pacesetting, and Coaching Styles (Goleman, 2000). Another suggestion or negotiation is for Dr. Dupres and the members of the board to increase the interaction and exposure of Ken to John Babcock and James McDermott. Being “legacies” in the Executive Group, they will be able to pass on their knowledge and techniques to Ken, before stepping down from the group. Moreover, Ken must also increase his exposure and interaction with the different functioning teams and other board members. Third is the suggestion that for Dr. Dupres to fully function as the Board’s Chairman, and to focus on one main responsibility only. Another is to assess the situation and performance of James Haworth to resolve Chairmanship conflicts, and to inform him about the decision of the board regarding Ken. Last but not the least suggestion is to enhance the communication and coordination of functioning teams to develop teamwork, through trainings and employee development. With trainings and employee development, the functioning teams can develop teamwork, which would help them perform their tasks and responsibilities better.             I believe that the negotiations that I proposed and negotiated are fair to Ken and Dr. Dupres because the negotiations are intended to improve their performance. With these negotiations, Ken Martin will have the chance to be coached and the chance to improve, being supported by the whole Executive Group. With the coaching and training of Ken, specific tasks and responsibilities will be given to him, in turn, to each of the members of the Executive Group as well. This will favor Ken because the training and coaching will add and improve his knowledge regarding his work, and even give him the chance to attain a good position in the company. The negotiations will also favor Dr. Dupres because if Ken will have the position of the CEO or CFO, he will be able to focus only on being the Chairman of the Board, giving him the opportunity to perform his tasks well. In this way, he will not blame himself as causing conflict and confusion in the performance of the organization.             Handling the case would favor the consulting firm because if this case will be successful then the consulting firm will be able to gain the continuous trust and confidence of the company. If ever the company will be encountering problems and dilemmas in the future, then the company or even the Executive Group will be seeking the advice, support and ideas of the consulting firm. With the good performance of the consulting firm, the company will be seeking constant advice and solution from the firm, in turn establishing the company’s loyalty to the consulting firm in their aim for client satisfaction. In addition, the consulting firm will be regarded as part of the company’s success and long-term development. The negotiations will also favor the Executive Team because with the coaching and improvement of Ken, and the Chairmanship of Dr. Dupres, each member, will be given the chance to also improve on their work performance and responsibilities, in line with the delegation of new responsibilities of Ken and Dr. Dupres. It would be easier for the team to delineate their tasks and responsibilities better, and effectively and efficiently work on their teamwork, communication and coordination. This would help members to function better in the team, and to work efficiently and effectively with their new team leaders. In addition, working together would enhance their ability to innovate, and provide solutions to the arising problems, such as employee conflicts, financial problems and many others.             The negotiations would also favor the board members, including John Babcock and James McDermott because they will be able to share their knowledge and skills before stepping down from the company. In this way, they have contributed well to the welfare of the Executive Team, by helping Ken to improve on his skills and knowledge. However, in relation to James Haworth and the issue regarding Chairmanship, it would be better if James Haworth will be leaving the responsibility of being a Chairman to Dr. Dupres, being incapable of leading. However, because Ken Martin is a representative of James Haworth, James can still have a say on Board matters, especially with controlling 25% of the company’s stocks.             I believe that aside from the parties already involved and discussed, there should be no more parties to be involved in this matter to maintain the secrecy and confidentiality of the situation. It is enough that only the important members of the company, such as the Board and the Executive Team know the situation, so as not to complicate the matter. These people are responsible for decision-making and their views and opinions regarding the situation will be most important. The views and opinions of these individuals must be considered because they have the authority to do so, and to make sure of coming up with relevant and wise decisions regarding the situation.             Credit:ivythesis.typepad.com

Sample Critical Discussion about a company’s Leadership and problems of the board that will be useful in the assessment of the situation

Unit 1 – DB Discussion on Consultation Notes Given the presented situation of Dr. Jean Paul Dupres, I was able to observe an...

Child sexual abuse: a marker or magnifying glass for family dysfunction?

Child sexual abuse: a marker or magnifying glass for family dysfunction? Abstract A report of child sexual abuse leads to a multi-agency investigation that often reveals other maltreatment and dysfunctional behaviors within the farnily. Due to recent developments in this field, the emphasis of the investigation has shifted to the child’s history rather than information from the parent or accused, or the presence of injuries. In the last 10 years C’hildren’s Advocacy Centers have become a central component to the investigation of child sexual abuse and provide a means for long-term follow-up of referred families. The idiosyncrasies of this investigative and advocacy system have provided an in-depth view of the families of sexually abused children. Four family types emerge: safe and secure, safe and insecure, unsafe and enmeshed, and unsafe and insecure. The characteristics of child sexual abuse, the response to the child’s disclosure of abuse, and the prognosis for the child victim vary among the -different family types. An innovative long-term program of wrap-around services for sexually abused children and their families provides counseling, peer activities, family mentoring, and child mentoring while tracking the symptoms and behaviors of the child victims. The identification of a child victim of sextial abuse can be a tragic crisis and an opportunity for intensive and timely intervention. 1. Introduction How can sexual abuse be a marker or magnifying glass for family dysfunction? The answer lies in part with legal definitions and with the unique way that child sexual abuse cases are investigated. All 50 states have laws mandating the report of suspected child abuse to authorities, usually law enforcement or child protection agencies. Of the four types of child maltreatment, sexual abuse is most clearly recognized by society and most clearly defined by laws. Most Americans would agree that when an adult touches the genitals of an 8-year-old girl in a sexual manner it is inappropriate and unlawful. Some would agree that when a father strikes his 8-year-old daughter in the buttocks with a belt and leaves bruises that it is perhaps excessive and inappropriate, but fewer would agree that the act merits criminal prosecution. Few would agree that if a father yelled at his 8-year-old daughter and repeatedly called her an “ugly idiot,” or left her alone for 4 hr at night that either incident should be reported for emotional abuse or neglect and the father prosecuted for his actions. The laws are generally vague and unhelpful in defining what constitutes “abuse” in our society. For example, in the Texas Family Code Section 261.001 (ref.) physical abuse is defined by such terms as “substantial harm … excluding reasonable discipline by a parent,” and emotional abuse is “mental or emotional injury … that results in observable and material impairment in the child’s growth, development, or psychological functioning.” The latter definition is flawed by the fact that “mental injury” can rarely be attributed specifically to some “observable and material impairment” in the child’s functioning over a period of time that would effect his growth and development. Both definitions are hampered by subjective terms that leave the decision to report abuse up to the reporter and his or her personal threshold for what is tolerable. What is “substantial harm?” What is “reasonable discipline?” A number of parents are unreasonable when they mete out punishment, but the definitions refer more to the outcome of such acts (the injuries received by the child) rather than the parent’s state of mind when the punishment is rendered. To these unreasonable parents, the discipline they give is entirely reasonable and they are usually unwilling to admit that they exercised poor judgment unless the injury results in death or devastating injury. The definition of neglect does not include age guidelines for when children may be left unsupervised but relies on the reporter to determine when a child is “exposed to substantial risk of physical or mental harm” or when a child is in a situation “that a reasonable person would realize requires judgment or actions beyond the child’s level of maturity. . .” In contrast, sexual abuse definitions in the Texas Family Code are primarily referenced to the Penal Code Sections 22.021 and 43.01 and provide more concrete parameters for what constitutes sexual abuse. Examples from these sections include: ‘Touching of the anus, breasts or any part of the genitals … with intent to arouse or gratify the sexual desire of any person’; ‘penetration of the anus or female sex organ of a child by any means’; ‘penetration of the mouth of a child by the sex organ’ of another person; and ‘causing the sexual organ of the child to contact or penetrate the mouth, anus, or sexual organ of another person.’ While terms such as “female sex organ” are somewhat vague and the “intent to arouse or gratify the sexual desire of any person” depends primarily on the sexual offender’s confession, these definitions are far more specific than those for physical or emotional abuse. While definitions for physical and emotional abuse depend more on adult definitions of what is “reasonable” or “substantial,” sexual abuse definitions rely on the child’s report that specific types of sexual contact have occurred. Not surprisingly, the system responses to a report of sexual abuse generally differ from the responses to a report of suspected physical abuse, emotional abuse or neglect. While Child Protective Services receives the bulk of all child maltreatment referrals, very few of the physical abuse, emotional abuse and neglect cases are criminally investigated or prosecuted. While the threshold for reporting abuse is a “suspicion,” the threshold for a criminal conviction is “beyond a reasonable doubt.” Victims of severe physical abuse and neglect are usually very young children incapable of testimony due to their developmental immaturity or the severity of their injury. Without the key testimony of the child, abusers rarely feel compelled to admit guilt. A criminal prosecutor must prove that a specific person “knowingly and willingly” caused the injury(s) in the child. This is often problematic when several people have cared for the child during the time frame of the injury. Unlike sexual abuse cases, investigations of physical abuse, emotional abuse, and neglect are hampered by questions of intentionality which can be definitively answered only by the suspected abuser, and questions of parental rights to render what they consider to be “reasonable discipline.” Due to these difficulties, abusers rarely admit to their acts and rarely agree to accepting services to modify their behavior. Sexual abuse victims are generally older children and fully capable of providing statements and testimony. Sexual abuse investigations rely primarily on the child’s statements since physical injuries and evidence are generally laclcing (refs.). Since information critical to the investigation is more readily available, most sexual abuse investigations involve both Child Protective Services and law enforcement. One role of Children’s Advocacy Centers is to facilitate and coordinate joint investigations between these two agencies, and to provide a means for follow-up and monitoring of sexual abuse cases. As a result, sexual abuse cases tend to be more straightforward than other types of abuse and mnore effectively investigated. With the added long-term involvement of child advocacy centers, issues of family dysfunction and violence often surface. The purpose of this paper is to describe the families of sexually abused children within the context of the child victim’s experience, disclosure, immediate responses to disclosure, and long-term effects of abuse. This discussion will provide the rationale for an innovative long-term intervention and prevention program provided to sexually abused children and their families. 2. Literature review/background Sexual abuse is a common childhood problem. National U.S. statistics (Wang & Dara, 1997) indicate that more than 200,000 children are reported to Child Protective Services each year for suspected sexual abuse. Estimated numbers are much higher; the more conservative figures indicate that as many as one female in four and one male in six will experience sexual abuse prior to their 18th birthday (Hopper, 1997; Lechner, Vogel, Garcia-Shelton, Seichter, & Steibel, 1993; Lewin, 1997). The discrepancy in reported and estimated numbers suggest that child sexual abuse remains a significantly underdetected and underreported problem. A primary reason for underdetection is that a significant number of child victims do not disclose their abuse. Approximately 90% of child sexual abuse cases are first detected when a child discloses to someone; the remainder arc: detected when the abuse is either inadvertently witnessed or discovered in the victim’s diary or pornographic photographs (Kellogg & Menard, 2002). In a study of young adults that were sexually abused as children, only 75% disclosed their abuse during childhood (Kellogg & Hoffman, 1995). In addition, health professionals rarely detect physical signs of sexual abuse since more than 80% of examinations are normal (Berenson, Wiemann, & McCombs, 2001; Kellogg & Adams, 2002) and because general practitioners rarely have the knowledge or expertise to detect the subtle signs of trauma associated with sexual abuse or assault. While schools may encourage disclosure with various preventative programs, one study (Kellogg & Huston, 1995) found that children first disclose to school personnel in only 10% of cases. Reasons for underreporting to authorities are often linked to adult responses when a child first discloses sexual abuse. Adults may believe the child and report promptly, believe the child but delay or avoid reporting, or not believe the child and not report. In one study (Kellogg & Huston, 1995) only half of the child victims that disclosed abuse were helped in a way that terminated the abuse. In another study (Kellogg & Menard, 2002) the response to disclosure or discovery of sexual abuse was supportive in 63% of cases. In these cases, the abuse was reported, the nonabusive custodial adult believed and supported the child victim and the perpetrator was denied access to the child victim. In 18% of cases the response to disclosure or discovery of abuse was not supportive: the child was not believed and the abuse was either not reported or the abuse was reported but the child victim was not believed. In some of these cases, the child first told a family member, family member did not report, and the child later told a nonfamily member who did report. In other cases, the child was punished for disclosing abuse. The remainder (17%) of responses to disclosure or discovery of abuse were neutral; it was unclear whether the nonabusive adult caretakers supported or believed the child victim. The first adult family member that the child discloses to is frequently the mother. The mother of the sexually abused child not only plays a pivotal role in the child’s likelihood of disclosure, but also in the risk factors that give rise to the abuse. Sexual abuse is not considered a random event. Well-documented risk factors include: (1) Presence of a step-father or other father figure. (2) Living without the mother at some interval. (3) Lack of matemal education (did not finish high school). (4) Lack of emotional closeness to the mother. (5) Sexually repressive mother. (6) Lack of physical affection from the father. (7) Family income less than ,000 per year. (8) Fewer than three friends in childhood (Finkelhor, 1979). These risk factors are cumulative such that each additional factor increases the child’s vulnerability by 10-20%. All but one of these factors involve the mother or mother’s choice of partner(s). Considering that most sexual offenders of children are adult family members (Burge, Katerndahl, & Kellogg, 2001; Kellogg & Hoffman, 1995), the mother’s decisions in life and role within the family are integral to the safety and well-being of her children. In one study (Burge et al., 2001) of 100 adult female survivors of childhood sexual abuse, the families of origin were characterized by dysfunction and loss. Half experienced a loss of a biological parent through divorce or death at the average age of 7 years (median 5 years). During elementary school years parental loss may disturb the achievement of normal developmental goals at this age that include self-esteem, autonomy, and the identification and adaptation of appropriate role models, primarily family members. Seventy percent of adult survivors of child sexual abuse experienced the death of a family member prior to turning 18; 15% experienced the death of their father. Among those who experienced sexual abuse during the elementary and middle school years, the prevalence and severity of adult psychopathology was greater than in those experiencing sexual abuse in later childhood years (Katemdahl, Burge, & Kellogg, 2001). It may be that the dissolution of the family structure through divorce or death potentiates the effects of child sexual abuse or creates greater risk of exposure to sexual offenders of children. In this study, 68% were victimized by family members and more than two-thirds of these perpetrators lived with the child. The effects of sexual abuse are similar to emotional abuse rather than physical abuse. Given that most sexual offenders desire a relationship with their child victims, deception and threats are commonly used to gamer the cooperation and secrecy of their victims. Children are taught and expected to obey the significant adults in their life and these adults are assumed to be protective and moral. Depending on the approach of the abuser, the child victim may experience either confusion or fear at the onset of abuse. If the sexual offender approaches the child with deception and enticement the child may be unable to reconcile the expected protective and moral role of the adult with his or her actions. Depending on the age and individual characteristics of the child, abuse factors, and family circumstances. the child may either redefine the adult role and accommodate (“I have to do whatever my father says”) or redefine the adult role and report (“Even if his is my father, he is doing something wrong”). If the sexual offender uses threats to gain sexual access to the child, most children feel helpless and comply with the demand for secrecy. The importance of secrecy is evident in the fact that most sexual offenders explicitly or implicitly warn their victims not to “tell” after the first episode of abuse. As the abuse continues, the threats become more specific and ominous and the child’s sense of helplessness deepens. These threats often reflect the family dysfunction and the child’s greatest fears: “Don’t tell or I’ll beat up your morr and come back to kill you all”; “Don’t tell ,cause your mom won’t believe you anyway”; “Don’t tell or they’ll take you away from your mom”; or “If you tell I’ll go to jail and your little sister won’t have a daddy.” These threats are often effective and may delay or deter the child’s diisclosure. In one study (Kellogg & Huston, 1995), sexually abused children and adults abused as children waited an average of 2.3 years (median 5-6 months) before disclosure. The reasons child victims delay disclosure reflect the effectiveness of their abuser’s threats. Fear of perpetrator* 34% Fear of getting in trouble 21% Fear of not being believed 13% Fear of effects on family 10% Fear of effects on perpetrator 8% No reason specified 8% Did not know it was wrong 2% Liked it 2% Embarrassed 2% * This response was more common in subjects from violent homes (p < .05). 3. Findings: a proposed model of family types Families can protect or harm, by active choice or by passive neglect. Protection can be primary: parents that do not maltreat their children; or secondary: parents that promptly report their child’s maltreatment and who believe and support them. Families that protect their children by choice are child-centered; they have relatively stable family structures, little adult dysfunction, and good parental-child bonding. Families that are unintentionally neglectful and lapse in protecting their children are impaired by adult-centered issues: lack of stable family structure, lack of parental-child bonding, overwhelmed by adult mental health problems, criminal behavior, alcohol or drug addictions and intrafamilial violence. Four types of families emerge from Table 1: safe, secure (child-centered, stable, protective family); safe, insecure (nonabusive but dysfunctional adults who place their children at risk for abuse); unsafe, enmeshed (enmeshed abusive family); and unsafe, unstable (abusive and dysfunctional adults). 3.1. Safe, securefamilies Based on studies of child sexual abuse victims, most do not live within families that lack dysfunctional, unprotective, and abusive behaviors. In one study more than half of child sexual assault victims reported adult domestic violence in their homes and only 20% reported they had never lived with a violent or sexually abusive adult male (Kellogg & Menard, 2002). In another study of 100 females that were survivors of child sexual abuse only 15% reported that none of their immediate or extended family members were heavy drinkers, drug abusers, arrested for drug or alcohol-related crimes, arrested for assault or diagnosed with a mental health problem (Burge et al., 2001). In a study of sexually abused children, 63% indicated that the adult response to their disclosure of abuse was supportive: the abuse was reported, the nonabusive custodial adult believed and supported the child victim, and the perpetrator was denied access to the child victim (Kellogg & Menard, 2002). While this result is encouraging, it is prejudiced by the fact that children in this study would not have been identified if their abuse had not been reported by some supportive adult. Not surprisingly, another study of young adults sexually abused as children found that while most victims did disclose in childhood, only half of those that did disclose indicated that the abuse stopped after disclosure (Kellogg & Huston, 1995). Children in safe and secure families that do suffer sexual abuse tend to experience less severe forms (nonpenetrative sexual acts). Maternal and paternal bonding, lack of drinking problems in the father, and lack of violence by the mother against the father are all related to lower severity of sexual abuse against the child (Burge et al., 2001). Less adult psychopathology in survivors of child sexual abuse is associated with lack of family (of origin) alcohol abuse and lower frequency of abuse (Katerndahl et al., 2001). Safe, secure, and child-centered families appear to protect children from abuse, moderate the severity of abuse and ensure a more favorable prognosis for the child’s recovery from abuse. 3.2. Safe, insecurefamilies A safe, but insecure family poses a considerable risk to children for abuse. This type of family is insecure for children because the adult dysfunctional behaviors overshadow the bonding, nurturing, and protection of children. These families may be characterized by loss: 40% of adult survivors of child sexual abuse have lost a parent due to divorce and 17% have lost a parent due to death during their childhood (Burge et al., 2001). Several documented risk factors for child sexual abuse concern family problems or challenges, including the presence of a step-father or other father figure and living without the mother at some interval (Finkelhor, 1979). Dysfunction in families of sexually abused children is common and takes many forms: 61% of fathers and 32% of mothers are described by their children as heavy drinkers or drug users, having been arrested for drug or violence-related crimes, or having mental health illnesses (Burge et al., 2001). Half of the adult survivors of child sexual abuse report that their fathers hurt their mother and a third did so while drinking; 18% of beaten mothers visited a physician for treatment of their injuries. In the same study, 22% of adult survivors of child sexual abuse indicated that their mother hurt their father, and 6% did so while drinking; 4% of the beaten fathers visited a physician for treatment of their injuries (Burge et al., 2001). Family dysfunction appears to increase the risk of child abuse by either compromising the protective skills of the caretakers and/or by increasing access of perpetrators to children. Child victims of multiple perpetrators are more likely to come from families characterized by spousal violence or by at least one adult with an alcohol or drug problem when compared with children victimized by only one perpetrator (Kellogg & Hoffman, 1997). Substance abuse may impair parental supervision of children. Since many sexual offenders of children are substance abusers (Edwall & Hoffman, 1988; Faust, Runyan, & Kenny, 1995). many children of substance abusing parents may be more accessible and vulnerable to sexual offenders their parents are acquainted with. Family dysfunction may also impair the parent’s ability and willingness to respond appropriately when their child discloses abuse. Most sexually abused children first disclose to a peer rather than an adult (Kellogg & Huston, 1995). Children in dysfunctional homes may be less inclined to disclose abuse to their parents when there has been less optimal parental-child bonding. 3.3. Unsafe, enmeshed families The unsafe and enmeshed family is a stable but isolated family that is controlled by an abusive father figure. The children, and other adults, typically the mother, are integrated into a rigid system of functioning determined entirely by the abusive head of the family, usually the father or a father figure. There are no known dysfunctional behaviors among the controlled adults primarily because the abuser does not allow such information to be shared. It is not unusual for the “subordinate” adult to have considerable mental health problems but it is unusual for that adult to have any opportunity to seek any form of help. Adults in families of victimized children are more likely to have poor communication skills, confused roles, and difficulty with problem-solving (Alexander, 1985; Courtois, 1988; Finkelhor, 1979; Hoagwood, 1990). Such families may also be remote from other means of social support (Ray, Jackson, & Townsley, 1991). Mothers may be ineffectual due to their partner’s abusive behavior and control and their own mental health problems stemming from their maltreatment. Wife battery significantly increases the risks for child sexual abuse (McCloskey, Figueredo, & Koss, 1995) and is associated with child physical abuse as well (Saunders, 1994; Stacey & Shupe, 1983). The children in the enmeshed family may be bonded to the mother because they view her as a safe haven from the father or because they wish to protect her from the father. The mother, in turn, may become pathologically dependent on her children’s love to counterbalance the stress of her adult relationship. The children sense that the mother is ineffectual in her dealings with the controlling father figure. They may doubt her ability to respond to a disclosure of sexual abuse by the father. This doubt is weighed with other fears. They may fear that disclosure will result in severe punishment of all family members. They fear their mother will side with the abuser since she too seems helpless to his whims. Because they are closely bonded with her, some child victims will opt to disclose to their mother. The mother, out of dependence or fear of the perpetrator will typically attempt ineffective alternatives to reporting in order to stop the abuse. She may arrange for a lock on the child’s bedroom door or “never leave her alone” with the perpetrator. Often, the child’s fears and doubts of the mother’s response to their disclosure results in considerable delay of their disclosure. As may be expected, the prognosis for children in an enmeshed family with a father figure perpetrator depends primarily on the mother’s response to their disclosure of sexual abuse. If the mother believes, supports and protects her children, then the prognosis for recovery is good as long as the mother does not succumb to the apologies and pleas for family reunification that commonly follow when the perpetrator is controlling and manipulative. If the mother reacts to the disclosure with ineffective measures, disbelief, or ambivalence, the children are more likely to recant. Unfortunately, children in enmeshed families often do not disclose to adults outside their home because of a strong sense of entrapment and general lack of adult relationships and friendships outside the home. 3.4. Unsafe, insecure families The unsafe, insecure, and adult-centered family is comprised of a mother who has multiple, short-term volatile relationships with various men and may have children with different fathers. The adult relationships are characterized by the same dysfunctions as the safe, insecure family: drug/alcohol abuse, violence, crime, low education, unemployment, and mental health problems. The difference is that the adult males are abusive to the children and frequently to other adult family members as well. This abuse may be physical and/or sexual, and is invariably emotional. The difference between unsafe insecLire families and unsafe enmeshed families is that both the mother and father figure in the unsafe insecure family are typically abusive and dysfunctional but in the enmeshed family the father is the only abuser and adult dysfunction is minimized or covert. Children in a sexual abuse clinic were surveyed about all the adult males that had ever lived in their home. While the most common response was that no father figure had been physically or sexually abusive to any household member (20%c), 19% indicated they had lived with at least one father figure that was sexually and physically violent to all the children and physically violent to their mother (Kellogg & Menard, 2002). Less common were father figures that were either physically violent or sexually abusive to the children or adult females. The adult relationships are often short-term and sometimes terminated when one partner is incarcerated for a crime but more often because the relationships are based on self-serving pleasure rather than commitment. This self-serving need may be drugs, crime, or sexual variety. Children living in unsafe, unstable families may be victims of sexual and/or physical abuse by multiple adults living with them throughout their childhood. Because the adult relationships are volatile and short-term, the abuse of the children may be short-term but repetitive and variable. They may be victims of neglect as infants, physical abuse as toddlers, sexual abuse as school-age children, and emotional abuse all their lives. They are not bonded with any adults in their home and have not learned to trust any adults outside the home. Disclosure of abuse may be accidental; a child may tell a peer of their maltreatment without expecting a reaction or even recognition that such incidents are inappropriate. Some of these peers may inform an adult who then makes a report to authorities. Abused children in unstable homes may panic and recant their statements because they fear unforeseen consequences and because they feel they have no other haven, safe or unsafe. Those that recant are unlikely to “let it slip out” again when they are abused by another adult. The mother in an unsafe, unstable family may indicate her abused child is known to be a “liar” and “never liked him (the abuser) anyway.” Because the mother often has the prior experience of being reported to child protective authorities for physical abuse or neglect, she is usually defensive and uncooperative when the sexual abuse is reported. She may have little remorse when her children are taken into protective custody, and may feel more freedom to pursue her own needs. She chooses her adult partner over her children. These children confront one of two dismal outcomes: stop the abuse and lose their mother (disclose) or keep their mother and continue the abuse (don’t disclose). Many children forego or delay disclosure in favor of the latter option. Regardless, the prognosis for psychological recovery in these children is fair to poor. 4. Discussion: intervention strategy Intervention for sexually abused children must incorporate the family and be initiated at an appropriate interval. Dysfunctional families may use excessive or inappropriate corporal punishment and provide role models that promote the development of delinquent behaviors, substance abuse, and unsafe sexual practices in the children. When do these behaviors in children and adolescents begin? In a study of 166 pregnant or parenting adolescents, more than half (54%) indicated they had a forced sexual encounter or a sexual encounter with a person more than 4 years older during their childhood or teen years (Kellogg et al., 2000). In this latter group, they indicated when they were first subjected to a variety of behaviors and activities. Behavior Age first occurred (years) Hit or hurt by a family member 11.5 Age first forced or illegal sexual experience* 11.6 Hit in the face by a family member 12.7 Hit with a fist by a family member 13.4 Use of illegal drugs 14.1 Alcohol intoxication 14.4 Runaway 14.5 Age first wanted sexual experience 14.9 First pregnancy 16.0 * Illegal sexual experience is a sexual experience with a person 4 or more years older that was not coercive from the subject’s perspective (Kellogg et al., 2000). This timeline indicates that, on average, most child maltreatment begins during the late childhood/early adolescent years and occurs over a relatively narrow time frame of 3-4 years such that by mid adolescence the sexually abusecl child has engaged in many of the health risky behaviors. Because the sexual abuse occurs early in this timeline and because most (80%; Alamo Children’s Advocacy Center data) sexually abused children presenting for evaluations are under the age of 13 years, intervention during childhood years is optimal. Based on the foregoing discussion, a report of child sexual abuse can provide a magnifying glass for family dysfunction. The identification of a child victim of sexual abuse can be a tragic crisis and an opportunity for intensive and timely intervention. This intervention should be multifaceted, targeting nonabusive adults, children and victims for several months or years. Provided services should be individualized to the needs and problems of each family. The Child Abuse Resource Enhancement (CARE) Project in San Antonio, Texas is an example of a long-term, multifaceted intervention program for sexually abused children and their families. This program is based on the following premises: (1) Most (80%) children and adolescents presenting for sexual abuse evaluations are under 13 years of age. (2) Most dysfunctional and health risky behaviors in abused children appear by age 14. (3) Risk factors for sexual abuse include family factors such as dysfunction and methods of discipline. (4) The child victim’s perception of the parents’ reaction to their abuse impacts their tendency to disclose abuse and their recovery. (5) The choices a custodial parent makes with regards to partners and support of their children impact the child’s risk for abuse, use of illicit substances, and health risky or delinquent behaviors. These risks in childhood impact the child’s capacity to become a protective and secure parent. The goals of the CARE Project are to (1) reduce the likelihood of future substance abuse, adolescent pregnancy, and other high-risk behaviors with adverse health and legal consequences for girls and boys, age 6-12, that have been sexually abused, (2) enhance the protective and parenting skills of the nonabusive custodial parent; and (3) maximize the potential for sexually abused children to become protective and secure parents to their own future children. The specific project objectives include: (I) Provide new long-term services to sexually abused children; the point of contact for these children will be the Alamo Children’s Advocacy Center when they are referred by Child Protective Services or law enforcement for medical evaluations. (2) Increase the number and duration of services received by sexually abused children and their family members beyond the current short-term medical and counseling services. (3) Through therapy and mentoring, reduce the trauma experienced by abused children, as measured by the diminution of symptoms of anxiety, depression, dissociation, anger, and post-traumatic stress. (4) Through various counseling, mentoring, and peer activities, provide abused children and their families with the support, knowledge and social skills necessary to develop healthy and appropriate relationships with family members and others. (5) By establishing mentoring relationships with carefully screened adults, provide abused children with individual support and positive role models. (6) Increase the resiliency of abused children and enhance their resistance to destructive and unhealthy behaviors in adolescence. (7) Conduct a prospective long-term study of outcomes in sexually abused children enrolled in this program, identify which interventions enhance child resiliency and family stability, and develop an intervention/prevention model for abused children and their families that can be incorporated readily into other communities. Utilizing many community agencies, four broad categories of services are offered to sexually abused children and their families: counseling (family and child), medical services (child), mentoring (family and child), and peer activities (child). The collaborating agencies include the battered women’s shelter, Boy’s Club, Girl and Boy Scouts, YMCA/YWCA and Big Brothers and Sisters. Interventions are clinic-, home-, and school-based, and include both in-person and telephone contacts. Services are tailored to the needs and capabilities of the family, are offered over 4 years, and vary through time with the changing needs and desires of the family and children. CARE Project personnel provide case management, coordinate case review among collaborating agencies, collect and analyze data, provide some of the medical, counseling, and mentoring services, and conduct in-service training for all the collaborative agencies. Data collected includes: demographic information, number and types of services utilized, length of time services were utilized, family paychosocial data (gathered from the mother), child psychosocial functioning (gathered from the child), reactions to abuse (child and parent), use of physical discipline (child and family), and the Trauma Symptom Checklist for Children, a reliable and valid instrument developed by Dr. John B riere. The latter instrument is administered to children and repeated over 3-6 month intervals. As of September 2001, the CARE Project has been offering these services for 30 months. Some preliminary results and observations include: (1) There has been at least one adult substance abuser in 44% of the homes of sexually abused children. (2) Fifty-six percent of the mothers of sexually abused children have been victims of intimate partner physical and/or sexual violence and 44% suffered physical and/or sexual violence as children. Approximately two-thirds of the sexually abused children have been disciplined by physical means. (3) Nearly 30% of sexually abused children felt some degree of blame for the abuse and about a third did not think their nonabusive parent believed their disclosure of abuse completely. (4) About 85% of the 456 children and families that enrolled and participated in CARE utilized more than one of the services offered; only 23% that enrolled in CARE did not participate. The combination of counseling and peer activities is the most commonly utilized cluster of services. (5) On the Trauma Symptom Checklist for Children, 21% of sexually abused children worsened in at least one of the symptom groups through time; 51% improved or stabilized and 29% had both improvement and worsening in different symptom groups. About 15% had suicidal ideation at some time. These preliminary results suggest that the fami]ies enrolled in CARE are characterized by dysfunction and violence but nonetheless have high participation rates in the services offered through this project. Many of the sexually abused children feel guilt and suffer from symptoms of anxiety, stress, depression, dissociation, and anger but in most children these symptoms do improve with time. When the study is complete, comparisons between the outcomes in families that participated in CARE and those that idid not will enable the researchers to make recommendations for effective intervention. 5. Conclusions Due to the idiosyncrasies of the law and investigation, a report of child sexual abuse often reveals family dysfunction and instability. The mandated nature of the investigation provides an opportunity to begin intensive and long-tern intervention for both child victims and family members. When such intervention is effective parents of sexually abused children become more protective and sexually abused children have a better prognosis for recovery and for parenting their own future children. References Alexander. P. C. (1985). A systems theory conceptualization of incest. Family Process, 24, 79-88. Berenson, A. B., Wiemann, C. M., & McCombs, S. (2001). Exposure to violence and associated health-risk behaviors among adolescent girls. Archives of Pediatrics & Adolescent Medicine, 155, 1238-1242. Burge, S. K., Katerndahl, D. A., & Kellogg, N. D. (2001). Thefamily lives of adult survivors of child sexual abuse: A descriptive study. Manuscript in preparation. Courtois, C. A. (1988). Healing the incest wound. New York: Norton. Edwall, G. E., & Hoffman, N. G. (1988). Correlates of incest reported by adolescent girls in treatment for substance abuse. In L. E. A. Walker (Ed.), Handbook on sexual abuse of children (pp. 94-106). New York: Springer. Faust, J., Runyon, M. K., & Kenny, M. C. (1995). Family variables associated with the onset and impact of intrafamilial childhood unwanted sexual experiences. Clini;cal Psychology Review, 15, 443-446. Finkelhor, D. (1979). Sexually victimized children. New York: The Free Press. Hoagwood, K. (1990). Parental functioning and child sexual abuse. Child and Adolescent Social Work, 7, 377-387. Hopper, J. (1997). Prevalence, lasting effects, and resources (on-line). Available at: http:/Hwwwjimhopper.com/ male-ab#studies Katemdahl, D. A., Burge, S. K., & Kellogg, N. D. (2001). Predfictors of development of adult psychology in female victims of childhood sexual abuse. Manuscript in preparation. Kellog, N. D., & Adams, J. (2002). The role of clinical experlise and training in the interpretation of examination findings in suspected victims of child sexual abuse. Child Maltreatment (in review). Kellogg, N. D., Burge, S. K., & Taylor, E. R. (2000). Wanted and unwanted sexual experiences and family dysfunction during adolescence. Journal of Family Violence, 15(1), 55–68. Kellogg, N. D., & Hoffman, T. J. (1995). Unwanted and illegal sexual experiences in childhood and adolescence. Child Abuse & Neglect, 19(2), 1457-1468. Kellogg, N. D., & Hoffman, T. J. (1997). Child sexual revicl:imization by multiple perpetrators. Child Abuse & Neglect, 21(10), 953-964. Kellogg, N. D., & Huston, R. L. (1995). Unwanted sexual experiences in adolescents: Patterns of disclosure. Clinical Pediatrics, 34(6), 306-312. Kellogg, N. D., & Menard, S. (2002). Violence among family members of children evaluated for sexual abuse. Child Abuse and Neglect (in press). Lechner, M. E., Garcia-Shelton, L. M., Leichter, J. L., & Steibel, K. R. (1993). Self-reported medical problems of adult female survivors of sexual abuse. Journal of Family Practice, 36, 633-638. Lewin, T. (1997, October 1). Young victims often turn to alcohol, drugs, risky sex and suicidal thoughts. New York 7imes, 12. McCloskey, L. A., Figueredo, A. J., & Koss, M. P. (1995). The effects of systemic family violence on children’s mental health. Child Development, 66. 1239-1261. Ray, K. C., Jackson, J. L., & Townsley. R. M. (1991). Family environments of victims of intrafamilial and extrafamilial child sexual abuse. Journal of Family Violence, 6, 365-374. Saunders, D. G. (1994). Child custody decisions in families experiencing woman abuse. Social Work, 39, 51-59. Stacey, W., & Shupe, A. (1983). The familv secret. Boston: Beacon Press. Wang, C. T., & Dara, D. (1997). Current trends in child abuse reporting and fatalities: The results of the 1996 annualfifty state survey. Chicago, IL: National Committee to Prevent Child Abuse. Credit:ivythesis.typepad.com

Child sexual abuse: a marker or magnifying glass for family dysfunction?

Child sexual abuse: a marker or magnifying glass for family dysfunction? Abstract A report of child sexual abuse leads to a ...