ATI - Abuse, Aggression, and Violence Module

Abuse, Aggression, and Violence Across the Lifespan

Child Neglect, Abuse, and Maltreatment

The Child Abuse Prevention and Treatment Act (CAPTA) has defined child abuse and
neglect as "any recent act or failure to act on the part of a parent or caregiver that
results in death, serious physical or emotional harm, sexual abuse, or exploitation,
or an act or failure to act that presents an imminent risk of serious harm." Neglect
is generally defined as the failure of a caregiver to provide needed food, clothing,
shelter, medical care, or supervision to the degree that the child's health, safety,
and well-being are threatened with harm. 

The majority of the United States classifies the failure to educate a child as a type of
neglect. Some states classify medical neglect as failing to provide any special
medical treatment or mental health care needed by the child. A few states define
medical neglect as the withholding of medical treatment or nutrition from disabled
children with life-threatening conditions.

Abandonment
Some states list abandonment in their definitions of abuse or neglect, generally as a
type of neglect. The following scenarios can characterize abandonment: the
individual has been left in circumstances in which they suffer serious harm, a
caregiver’s identity or whereabouts are unknown, or the caregiver has failed to
maintain contact or provide reasonable support for a specified period of time.
While most often associated with children, abandonment of older or impaired
(cognitively or physically) adults also occurs. 

Intimate Partner Violence (IPV)

IPV is a significant yet avoidable health problem that affects millions of people.
Described as physical violence, sexual violence, stalking, or psychological
aggression by a current or former partner or spouse, it can occur among all types
of couples and does not require sexual intimacy. 

Varying in frequency and severity, IPV has touched 25% of women and 10% of men
in the United States. A significant number of people affected by IPV report that the
occurrence happened during their teenage years, referred to as teen dating
violence (TDV). While TDV can affect anyone, there is a higher risk among LGBTQ+
adolescents and teens. Dr. Lenore Walker, an expert on IPV, previously referred to
as domestic violence, originally created the three-phased “Cycle of Violence.”
This cycle of violence is applicable in all instances of aggression or violent acts and
is not limited to IPV. Survivors of IPV may develop subsequent medical issues
related to reproductive, cardiac, digestive, neuromuscular, and skeletal systems, in
addition to PTSD or a depressive disorder. They are more likely to participate in
behaviors detrimental to their health, such as unprotected sex, smoking, or
excessive consumption of alcoholic beverages. 
Older Adult Abuse
The people experiencing neglect, abuse, or financial exploitation are often those
who are more dependent upon others for daily care, including those with cognitive
impairment, physical disabilities, and those with few friends or family members.
This dependency increases as the ability to care for oneself decreases over time, as
seen in the older adult population. Older adults are at a higher risk of being
abused, and this abuse is classified as older adult abuse. This type of abuse can
happen anywhere and occurs in any relationship.

Rape and Sexual Assault

Rape includes forced sexual intercourse, including both psychological coercion as
well as physical force. Forced sexual intercourse involves penetration by the
offender(s). Individuals of all genders may be survivors of rape or perpetrators, as
rape can occur between all genders. Attempted rape includes verbal threats of
rape. Within the last 30 years, laws have been enacted in all states in the United
States against marital rape. Prior to that, exemptions existed allowing married
couples to have non-consensual sex with their spouse without worrying about legal
concerns. 

Statutory rape is defined as an adult having sex with an individual younger than 18
years of age, even if the minor consents to the act.

Over two-thirds of rape survivors know the individual who has committed the
attack. This is referred to as acquaintance rape and can involve friends, coworkers,
classmates, or a relative. These rapes are frequently not reported as the survivor
may fear repercussions from the perpetrator or may feel responsible in some way.
Survivors of rape need to remember that rape is always the fault of the perpetrator
and never their fault.
Sexual assault is defined by various crimes that include actual or attempted attacks
that involve unwanted sexual contact between survivor and offender. These attacks
include but are not limited to verbal threats, fondling, or grabbing. 

Stalking
Stalking consists of unwanted attention, such as threats or harassment, and
frequently involves individuals known to the person being stalked. Forty percent of
people who experienced stalking say it occurred before they were 25 years old, with
over 60% of them having experienced actual threats of physical injury. 

Approaches used by stalkers include the following.

 Following and watching their target

 Obtaining entry into target’s car or house and leaving items to let them know

they can enter at anytime

 Showing up unannounced at target’s home, workplace, or school 

 Nuisance phone calls, emails, text messages, etc. 

Nurses can help to minimize stalking by providing education about stalking

behaviors, engaging the community in efforts to prevent stalking, and helping to
facilitate safe environments. 

Bullying Behaviors
Bullying, considered an adverse childhood experience (ACE), is defined as uninvited
behaviors from one youth or group of youths to another that are aggressive in
nature. Customary forms of bullying include the following.

 Kicking, hitting, tripping 

 Teasing and name-calling 

 Excluding targets from group or spreading rumors

 Destruction of property belonging to target

The Centers for Disease Control and Prevention and Department of Education

include the core elements noted below when defining bullying to help distinguish
bullying from other forms of aggressive behavior: repeated bullying behaviors,
perceived or actual power imbalance, and unwanted aggressive behaviors.
Bullying
Bullying can happen in settings beyond schools as it can happen in clubs and
churches, and a growing issue is cyberbullying. Students aged 12 to 18 who are
bullied believe those who bullied them had more social influence, were physically
stronger, had more money, or were able to influence what others thought of them.
Online bullying or bullying via text (cyberbullying) accounts for 15% of the instances
of bullying among this age group. 

Interprofessional Team: Collaboration Strategies & Safety

The psychiatric mental health (PMH) nurse collaborates with all health care team
members to provide care to clients experiencing spiritual, physical, psychological,
and mental concerns in various settings. PMH nurses assist clients in achieving their
recovery goals, such as coping with manifestations of disease processes, helping
clients feel empowered and in control, and reshaping clients’ sense of self while
reigniting hope. 

The plan of care for clients with aggressive or violent behavior includes
implementing a client-centered care approach that consists of a comprehensive
medical exam, an assessment and utilization of reliable anger measurement tools,
and a mental status exam. As noted previously, nurses need to be aware of the
potential escalation of the client’s anxiety or aggression. To ensure the health care
team’s safety, integrating a staffing-centered approach to care is recommended,
including educational in-services for all team members regarding respectful and
nonconfrontational methodologies and de-escalation techniques. Finally,
environmental awareness is crucial, as clients should not feel they are confined to
small, heavily congested, or noisy areas. 
Additional preventive strategies employed by health care facilities include the
following.

 Visible list of standards of behavior that are discussed and agreed upon by

clients and staff 
 Sharing of effective de-escalation strategies amongst health care team 
 Frequent meetings among clients and staff with structured and limited
sharing 
 Availability of sensory items that can distract agitated clients
 Displaying positive messages from previous clients anonymously around the
unit 

Diagnostic and Laboratory Testing

Initial evaluation when dealing with a client with aggression and anger issues
should include a thorough history and physical examination, a comprehensive
neurological evaluation, and a psychiatric evaluation. Information on the adult or
child’s behaviors should come from more than one source. For example, if dealing
with a child, the child’s teacher should also be involved. 

Typical radiographic and diagnostic laboratory studies should be performed to

identify any underlying medical conditions. This can include a chest X-ray, complete
blood count (CBC), thyroid function studies, metabolic panel, urinalysis, and urine
drug screen. Other tests may be prescribed by the health care provider as deemed
necessary.

Interviewing Techniques With Persons Who Have Experienced Violence or

Abuse
Interviews for survivors of abuse, aggression, or violence should be thoughtfully
and strategically planned. The physical location of the interview and who will be
present are both important. In the event of possible or suspected abuse by the
person accompanying the client, the interview should take place away from the
otherperson. All the people at the interview should introduce themselves and
explain their roles.

The approach should be gradual and nonthreatening—more conversational than a

barrage of questions. Allow the injured party to have control during the process,
such as where they sit, when to take breaks, etc. Do not touch the survivor without
asking for permission to do so. Traumatic effects such as memory loss, lack of
focus, emotional reactivity, and multiple versions of a story may be exhibited during
interviews and should be treated respectfully.
Survivors may: 

 Deny anything happened.

 Be fearful of what will happen to them once they leave the facility.

 Be wary of health care professionals.

 Demonstrate a lack of concern about their own needs.

 Be sleep deprived or malnourished.

When caring for vulnerable populations, including children, older adults, and

individuals who have cognitive or emotional disabilities, reporting suspected abuse
or violent acts is mandatory, and nurses are considered mandatory reporters. Each
state has specific requirements for reporting, and the nurse is required to work
carefully with their health care organization to determine the process and
organizational protocols.
Prevention, Treatment, and Continuum of Care
Abuse, aggression, and violence can be associated with multiple neuropsychiatric
disorders, including, but not limited to, oppositional defiant disorder, conduct
disorder, antisocial personality disorder, and intermittent explosive disorder. For
more information, see Personality Disorders and Disruptive Behavioral Disorders.

As discussed earlier, recognition of behaviors that often precede aggressive or

violent acts can help to mitigate the occurrence by implementing de-escalation
techniques. Nurses should be aware that aggression can signify the client’s distress
or an unmet need. Utilization of a mental status exam (MSE) can help provide
insight into the client’s current status. 

Preventive approaches include leadership, skill, and role-modeling of best

practices. 
Nursing Responsibilities and Interventions During Acute Episodes of
Aggression
Nurses recognize that aggressive or violent acts have an underlying cause, often
associated with several factors, such as physical illnesses or personality disorders,
extreme psychological distress, actions of others, and physical environment.
Understanding the “why” behind the behavior assists nurses in determining a
course of action. 

Initially, nurses should implement nonpharmacological interventions and attempt

to defuse the situation by employing de-escalation techniques.

Strategies include removing the client from what may be annoying them, which
could be the staff or another client. Allowing the agitated client some space and
time to regain a calm demeanor in a safe place can prove helpful. Using both
nonverbal and verbal therapeutic communication strategies is essential to maintain
safety. Asking what you can do to help while acknowledging their distress is a basic
approach when dealing with agitated clients. Responding to potentially violent
clients in a calm manner may be difficult for the novice nurse but is essential.
Displaying any outward signs of anger or speaking in an angry tone can escalate the
situation.

Situational awareness is important when interacting with agitated and potentially

violent clients. Do not stand directly in front of or within arm's reach of a client and
avoid having clients feel they are trapped by blocking the doorway. Knowing the
layout of the area and how to remove yourself, if necessary, should be primary to
prevent injury to self. The staff is required to receive training in physical restraining
and isolation techniques in case the situation escalates to that level. The goal is to
“talk down” the client without having to use physical force, but in the event the
client has become destructive or a danger to self or others, more definitive action
will be required.

Pharmacological Interventions
For long-term control of aggression, dependent upon any underlying mental
disorder, antipsychotic medications can be used, including benzodiazepines, mood
stabilizers, anticonvulsants, and antidepressants. Awareness of potential adverse
reactions and interactions with other medications is important for the nurse to
monitor. 

When a client’s propensity for an aggressive act cannot be mediated through de-
escalation or an oral dose of one of the medications noted above, it is common to
administer an intramuscular (IM) injection. Psychiatrists have prescribed a
medication referred to as “B52,” which is a combination of 50 mg diphenhydramine,
5 mg haloperidol, and 2 mg lorazepam. Other medications administered may
include olanzapine, diazepam, chlorpromazine, midazolam, droperidol, lorazepam,
promethazine, and ziprasidone. 

For clients who have been physically restrained, administration of sedating

medications, such as lorazepam or haloperidol, is common. Health care providers
should use the smallest dosage possible to achieve the desired effects quickly but
not cause any harm. For more information, see Psychopharmacology.

Debriefing
Originally attributed to military sources, nurses use a debriefing process to review
data, actions, and outcomes following an aggressive or violent event. Debriefing
should occur in a timely manner to allow staff to digest what has occurred and
discuss their feelings and reactions. The overall intention of the debriefing is to
provide an avenue for staff to verbalize their thoughts in a nonthreatening and
nonjudgmental atmosphere while reducing the possibility of psychological harm to
self. Information gathered can be helpful for mitigating future incidents and
improving client outcomes.

The debriefing process is led by a facilitator and involves multiple stages to allow
the health care team to accomplish the following.

 Expectations are defined 

 Facts are stated 

 Thoughts are shared 

 Traumatic reactions are identified 

 Descriptions of cognitive or behavioral symptoms are noted 

 Effective coping strategies taught 

 Session ends on a positive note following summarization

Recognize Cues (Assessment/Data Collection)

The first step of the nursing process, assessment (data collection for PNs), presents
the nurse with clues as to the client’s mental and physical status. Manifestations of
these signs and awareness by the nurse can help to prevent abusive, aggressive,
and violent outbursts. This awareness by the nurse helps to predict potential
violence, allowing the nurse to intervene as needed.

Clients who are angry may display clenched fists, speak in a raised tone and
volume, and tend to avoid direct eye contact. Anger can lead to aggression and
abuse.

Other factors, often obtained during the history that can indicate the propensity for
abusive, aggressive, or violent acts include:

 Previous occurrence of violent, abusive, or aggressive acts. This includes

clients who have been exposed to abuse and aggressive/violent behaviors.
 Age and gender of client. Older adults are not as likely to engage in
violence, and women are less likely to do so.
 Socioeconomic status. Clients in lower socioeconomic environments are
more likely to act violently.
 Stress. Clients experiencing a loss, divorce, or unemployment within the past
year.
Use of Seclusion and Restraints Seclusion
Seclusion, limited to the treatment of self-injurious or violent clients, involves
confining a client by themselves in a room or area in which they are physically
prevented from leaving. Clients may, on occasion, when they recognize a need for
solitude, ask for a “time out” by stating, “I need a break.” Unlike seclusion, clients
are able to leave the time-out when they choose.

Restraints
Physical restraints include equipment or materials that decrease the client’s ability
to easily move the head, extremities, or trunk. Medications such as haloperidol,
midazolam, and diazepam can be used as a chemical restraint when they are
administered to manage the behavior of a client or impede their ability to move
freely. Utilizing restraints (and seclusion) should be minimally implemented by
qualified health care providers only when necessary and ensure that current
standards of practice are always followed. An important concept to keep in mind
is that the least restrictive method of behavior control should be pursued
first. Restraints may become necessary if seclusion has not evoked the
desired behavioral outcome and the client continues to be a risk for self-
harm. 

As stated in the American Psychiatric Nurses Association (APNA) standards of

practice, seclusion and/or the use of restraints is initiated only if other less
restricting measures have been unsuccessful in mitigating the implied danger to
self, client, or others. It is imperative that staff have been routinely educated
(annually) on the use of restrictive measures such as seclusion and restraint and
undergo regularly scheduled evaluations. Client privacy, confidentiality, and dignity
are to be maintained at all times during this process as well as recognition of
potential risks based on the client’s underlying conditions, such as cognitive
disability, frailty, or obesity. 

The therapeutic use of secluding and restraining is based on the principles of

containment, isolation, and reduction of sensory input with the overall intent of
ensuring safety for the client and staff. Neither seclusion nor restraints are to be
used in a punitive or coercive manner, nor as a convenience for the staff. 

Seclusion and/or restraints can be initiated by a qualified health care team

member, as noted above, during a behavioral emergency, followed by a
provider prescription. Five staff members apply the restraints to ensure safety—
one for each extremity and one for the head. Restraints are applied to the upper
extremities first and then the lower extremities. Clients are placed in a supine
position with one arm extended above their head and the other arm at their side.
Care should be taken to ensure restraints are not impeding circulation or causing
pain. 

Noted below are important considerations when initiating seclusion and/or

restraints.

 Adhere to facility guidelines

 Prescription from provider must include the reason for the seclusion or
restraint, length of time, type of restraints, and criteria needed for removal
from the secluded area or release of restraints
 Risk of harm to client is prevented by following standards of practice and
individualizing care provided
 Client is evaluated (face to face) by health care provider, RN, or physician’s
assistant (PA) within one hour
 Restrained clients are not to be left alone
 Continuous monitoring (every 15 min) and documentation by prepared staff
o Observe for any injuries
o Monitor for breathing or other physical difficulties
o Anticipate need for hygiene, hydration, toileting, nutritional intake, and
physical comfort
 Assessment by RN hourly to include physiological and mental status, V/S
(including pulse oximetry), review of circulatory status and skin integrity, and
offering fluids
 Document all medications administered
  If restraints have been applied, range of motion exercises are executed every
two hr
 All interactions with the client should encourage behavior that will promote
release from seclusion and/or restraint

Criteria for Release

Discontinuation of seclusion or restraint is determined by the client meeting the
behavioral criteria established at the onset, as assessed by the approved  health
care provider. On occasion, the release may become necessary if the client is
demonstrating an increase in lack of behavioral control and generating a higher
risk of harm to self. 

Evaluate Outcomes (Evaluation)

The final phase of the nursing process utilizes clinical judgment while evaluating
client outcomes. Nurses will evaluate clients’ responses to nursing interventions
and determine if the outcomes have been met or if changes in the plan of care
need to be made.

As mentioned earlier, a tool frequently used in psychiatric/mental health nursing is

debriefing. This involves meeting with the client and other pertinent individuals to
review, discuss, and document incidences that have occurred. Debriefing is always
completed for clients that have been placed in seclusion or restraints as soon as
possible following the discontinuation of the seclusion and/or removal of restraints.
Obtain permission from the client to include family members or other caregivers
that may contribute to the debriefing session, as they can provide suggestions for
adjusting the current treatment modalities.  

Intentional dialogue during a debriefing session should include the following.

 Discussion of any misperceptions 

 Display of support for client’s return to unit milieu
 Identification of different approaches to prevent subsequent
seclusion/restraint 
 Listening to the client’s point of view 
 Provide guidance to the client if they believe their rights have been violated 
 Recognition of any trauma that occurred 
 Adapt plan of care as needed 
Module Summary:

 Nurses may find it harder to recognize emotional abuse as no physical

evidence is visible.

 Displays of anger are not always negative and are not always followed by

aggressive actions.

 Children who have experienced higher incidences of ACEs, especially as an

older child, are more likely to develop adverse outcomes, including becoming

the aggressor.

 Clients may use displacement or undoing as defense mechanisms against

the tendency to become abusive, aggressive, or violent.

 Abandonment can occur with children, as well as physically or cognitively

impaired adults, and older adults.

 The cycle of violence includes a build-up phase where tensions escalate;

an acute battering phase where the abusive activity intensifies and

 is rage-filled; and the honeymoon or respite phase where the

perpetrator becomes apologetic and affectionate.

 Interviewing clients who have experienced abuse or violence should take

place away from the individual suspected of being the perpetrator.

 Implicit biases can negatively affect client care and should be addressed.

 Recognizing behaviors that habitually precede violent or aggressive acts can

help nurses to lessen the occurrence of aberrant actions.

 Nurses must maintain situational awareness when interacting with

agitated or potentially violent individuals to ensure safety.

 Debriefing is an integral aspect of nursing care following an aggressive

or violent event or when seclusion or restraint techniques have been

implemented.

 Lack of physical and mental stimulation in a mental health unit can lead to

boredom, which in turn leads to an increase in self-harm or aggressive acts

toward others.

 Seclusion and/or restraints are only to be used if less restrictive

measures have not been successful, and never in a punitive manner.

 Individuals use NSSH to cope with emotional distress, and while the intent is

not suicide, it is an indicator of a possible future suicidal act.

 NSSH is not to be thought of as attention-seeking or manipulative behaviors.