SUMMARY. Unfavorable socioeconomic conditions lead to an increase of the number of injuries in children from a high-risk environment. Based on the literature, inappropriate care for children is classified into groups. various modes of behavior of deprived children are supported by practical examples. The negative and positive attitudes of nursing personnel towards these children are considered.
Key words: maltreatment, sexual abuse, neglect, deprivation, hyperactivity, provocation, suppressed type of behavior
Acute or chronic illness, defect, or injury has a major impact on the affected person as well as his close social relations, particularly the family. The burden is not only physical but also psychological. Hospitalization is a psychological burden for an adult and even more so for a child with a burn injury. The pain which accompanies burn injury, separation from parents, change of environment, fear of strangers, fear of therapeutic procedures, and movement limitation all contribute to the psychological trauma of a burned child.
How patients and children, in particular, cope with this difficult situation depends above sill on:
It is desirable that the family background is functional and stable, allowing for physical as well as psychological development. However, children are not always lucky enough to grow up in a functional and stable family. Increasing unemployment and alcoholism among parents also brings about a rise in the number of deprived children. These children come from families with a low socioeconomic level, from hostels, diagnostic institutes, or refugee camps.
It is very important that the nursing personnel not only provides attention but also intervenes to compensate for the high-risk social environment. Inadequate care of a child has various manifestations:
It should come as little surprise that to date we have detected only one case of child maltreatment and no cases of sexual abuse. We more often encounter children who ate neglected and suffer from the lack of love and adequate positive stimuli from the environment the child lives in.
The clinical picture of emotional and social deprivation can vary. The most common manifestations of the behavior and communication of deprived children with others are:
Over a period of two years we have noticed 15 such cases. We would like to describe individual types of behavior in our patients.
Case Report 1
Socially hyperactive children quickly make contact with others. require attention and have no fear of strangers. However, their relationships are usually very superficial.
This type of behavior was characteristic for a ten-yearold Romany girl who was admitted to our unit after she was treated in another hospital. The true history of the injury was not known, and the girl changed the story about her injury throughout her hospitalization. She provided various accounts of being burnt by the candle of a birthday cake; however, the most likely explanation is that she and her siblings were hungry, and while they were trying to cook a meal she was burnt tending to the fire in a stove.
The girl had been in our department for ten months with breaks when she was placed in a diagnostic institute. She underwent surgery on several occasions. During her hospitalization she was very communicative and was not shy about initiating contact with the department personnel, shopkeepers, and other adult patients as well as children. She addressed the personnel by first names. Usually she was kind and friendly; however she could be offensive, stubborn, and authoritative. She claimed a privileged position towards the other children. She had many problems with learning and was below the standard expected of a child in first grade. However, she liked manual work when she did not have to concentrate for long. Nobody raised concerns about the status of her health and nobody visited her during her entire hospitalization.
The social worker found out that the mother was not interested in any of her four children, and her whereabouts were not known. Her father was in prison, and the child was living with her grandmother in a Romany community where basic hygienic conditions as well as social situation were very poor. After a temporary stay in the diagnostic institute - she would often call or write to us from there - she was placed in a children's home. We have no reports from there. All contact stopped.
Case Report 2
An example of "social provocation type", when the child demands attention by provocation - often by aggressive and destructive behavior - is a 14-year-old boy who was placed in a children's home because his parents were alcoholics. He had been treated in our department as a small child and was now hospitalized for scar correction in the popliteal area. Although the parents were allowed to visit the child, they hardly ever did. However, when they did visit him, with the boy's grandmother, they were all drunk. He maintained contact with his sister, who was in a different children's home, and we have witnessed their conversation, which contained strong and vulgar expressions. The boy was verbally and physically aggressive towards other patients, who often tried to avoid him; he also demanded other children's company. He was verbally inappropriate and aggressive towards the staff as well and demanded a lot of attention from them. It was obvious that he was seeking affection as well as attention. After completion of his treatment, he was returned to the children's home.
Case Report 3
The next manifestation of behavior and social relations is a suppressed type of behavior. In this case, the child is passive and apathetic towards his/her environment. A typical aspect of this type of behavior is lack of initiation.
A 3-year-old girl with seven siblings of Romany origin was admitted 23 hours after 2nd degree burn injury to 12% of her body surface with symptoms of dehydration and without any treatment of her wounds. The child was hypotrophic and infested with lice. She responded to questions with simple yes/no answers. She did not have basic hygienic habits and could not play. When a member of staff raised his or her voice to other children, she started to cry. She did not make social contact; however, when the staff communicated with her, she reacted positively. She took advantage of every opportunity to fecal herself when possible. This child is at present awaiting evaluation by a social worker and, depending on the conclusion, will either return to her family or be sent to a social institution.
Sometimes it is very difficult to approach maltreated children correctly. Sympathy with their fate can prompt an inappropriate attitude towards them, which involves spoiling them and giving them various presents. The child then expects the same treatment after being placed in an institution-but this is not possible.
It is obvious that an authoritative and distant approach, where the resentment of the staff is transferred to the patients, is as inappropriate as letting the child become too attached to the staff: ultimately, the child suffers - as do the staff themselves.
Only a friendly relationship full of understanding and empathy, truthfulness and honesty can help these children overcome problems associated with hospitalization. Improvement of their social environment and psychological condition is in the hands of the social workers and psychologists.
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