Elder Abuse and Neglect
ELDER ABUSE AND NEGLECT
The American family has historically been viewed as a sacrosanct institution for care of the individual—the inviolate haven of love, safety, and protection. Growing awareness of family violence, however, has shown this view to be faulty, first with the "discovery" of child neglect and abuse in the 1960s, followed by spouse abuse in the early 1970s, and elder neglect and abuse in the mid-1970s. Yet, Peter Stearns and Shulamit Reinharz believe that family violence, in general, and elder mistreatment, specifically, have existed since the beginning of human history. Early examples of elder neglect and abuse include adult sons killing their aged parents in Teutonic societies and Native American tribes abandoning their elders when they can no longer travel (Sumner).
Acceptance of these historical facts as evidence depends on one's definitions of elder abuse and neglect. The likelihood of disagreement is considerable, since these concepts are value-laden and typically trigger emotional responses before logical thought. In addition, the perception of violence varies from society to society, and culture to culture. William Sumner argues that either honor or destruction underpin societies. When it is the former, older adults are respected and honored, while with the latter they are viewed as societal burdens which sap the strength of the society. This negative view of older adults sets the stage for ageism and mistreatment.
Although mistreatment of older adults is probably not a new phenomenon, awareness that some elders are mistreated and interest in examining the problem are relatively new. Initial professional recognition occurred almost simultaneously in Great Britain and America. In 1975, G. R. Burston wrote of "granny bashing" and Robert Butler described the "battered old person syndrome." In 1978 Suzanne Steinmetz shared her "discovery" of battered elders. Over the succeeding years as more cases were uncovered, initial disbelief and denial have given way to acknowledgment of the societal problems of elder neglect and abuse. In the early 1980s, researchers began to investigate elder mistreatment, and the House Select Committee on Aging began a series of public hearings around the country.
Most of the early research, which viewed elder neglect as a more benign subtype of elder abuse, examined the extent and nature of elder mistreatment among older adults living alone or with family members, friends, or other relatives and caretakers in the community. The prevailing view was that elder mistreatment was a domestic issue; it occurred within the family.
The early studies documented the existence of elder abuse and neglect, but did not provide clear or consistent information on the antecedents, causes, or consequences, or on the characteristics of the perpetrators or victims. For example, many of the early researchers identified functional disability, impairment, or dependence of the older adult as common correlates of both elder abuse and neglect (Douglass, Hickey, and Noel; O'Malley et al.; Steuer and Austin). More recent studies, which employed comparison of elder abuse and elder neglect cases, have found these characteristics are correlated with elder neglect but not with abuse (Phillips; Pillemer; Wolf). Some experts in the field believe that elder neglect is not a subtype of elder abuse (Fulmer and Gould; Hudson, 1986, 1991; Pedrick-Cornell and Gelles). Yet most of the research has included elder neglect as a subtype of abuse, confounding the findings for these two main forms of elder mistreatment. A few researchers have addressed both in the same study but have analyzed the results separately, providing evidence that elder abuse and neglect are distinct phenomena with differing risk factors and perpetrators.
Definitions and types of abuse and neglect
Since the definitions used by researchers and in state statutes vary, one instance of agreement is presented. In 1988, a three-round Delphi study was conducted with a nationwide panel of elder mistreatment experts to reach agreement on the types of elder abuse and neglect and on the definition of each type (Hudson, 1991). These researchers, clinicians, educators, and policy makers produced a taxonomy of elder mistreatment (Figure 1) and theoretical definitions of the eleven categories identified (Figure 2). Further, the panel made decisions about four previously debated issues. First, that elder mistreatment is not limited to domestic violence, but also includes mistreatment of older adults by persons in professional and business roles that connote trust, such as lawyers, doctors, nurses, and nurses' aides. Second, elder neglect and abuse are distinct forms of elder mistreatment that would be most effectively studied separately. Third, intentional and unintentional forms of both elder abuse and neglect exist, and thus, intentionality is not an essential characteristics of either but, rather, an intervention issue. Last, dependence of the elder on the abuser or neglector is not an essential characteristic of either form, although it is commonly seen among victims of elder neglect (Hudson, 1991).
The five-level taxonomy produced was based on perpetrator behaviors. Level I, violence involving older adults, fits elder mistreatment into the scheme of violence phenomena while distinguishing it from violence involving persons of other ages. Level II, which is based on the relationship between perpetrator and victim, differentiates elder mistreatment from two closely related phenomena that involve harm to older adults—self-mistreatment and crime against elders by strangers. Level II also broadens the concept of elder mistreatment beyond domestic mistreatment to include professional mistreatment of elders. Level III is based on the manner in which the harmful behavior is carried out, that is, by commission (abuse) or omission (neglect). Level IV, based on the purpose of the destructive behavior, promotes awareness that elder abuse and neglect occur intentionally and unintentionally, and conveys the experts' belief that detection can occur without the determination of intent or placement of blame. Level V focuses on the specific type of harmful behaviors involved in elder neglect and abuse. Categories include theoretically distinct behaviors that often are not mutually exclusive in actuality, so that a case may fit into more than one category. For example, the adult son who threatens and beats his mother while stealing her money fits into the categories of physical, psychological, and financial abuse; an adult daughter who has the needed resources but allows her frail mother to unsafely live alone in an unmaintained home and to become isolated, malnourished, and injured from falling fits into the categories of physical, social, psychological, and financial neglect (Hudson, 1991). As the taxonomy levels proceed from general to specific, definitions of the more specific forms of neglect and abuse build from the general ones.
Elder neglect is the careless, indifferent, or malicious lack of attention by a designated or implied caregiver that results in harm from an elder's basic human needs not being met. This lack of action, or omission, makes neglect less tangible and more amorphous than elder abuse, because abuse is typically seen as an act of commission, or the misuse of power and/or the use of force, such as beating, shoving, confining, threatening, or belittling an elder. Because neglect is a lack of action, it is often not recognized until its cumulative effects are seen on the elder. Acts of neglect range in severity from intermittent inattention to an elder's daily fluid intake to total abandonment of an incapacitated elder. While the dynamics of elder neglect are different from those of abuse, the effects on the elder can be equally dire—premature death that is due to malnutrition, dehydration, untreated medical conditions, hypothermia, imposed immobility, and so on—rather than death from injuries due to assault. Although neglect is the most common form of elder mistreatment, surprisingly, it is also the form that has been given the least attention by researchers. Therefore, we know far less about elder neglect per se than we do about elder abuse. While both healthy and frail elders of various ages are abused, it is frail elders of advanced age—eighty years and older and dependent on others for their basic care—who are most at risk for neglect.
Incidence and prevalence
Determining the incidence and prevalence of elder abuse and neglect is very difficult, mainly because most cases are not known to anyone out-side of the situation. Also, differing definitions of abuse and neglect, reporting agencies not keeping adequate information, and important differences in study methods have made reliable data elusive. While the actual incidence and prevalence of elder mistreatment in domestic and institutional settings is unknown and can only be estimated, all of the studies clearly indicate that most cases are unreported in spite of mandatory reporting laws in all fifty states. Nevertheless, estimates from five studies provide some indications of the extent of elder neglect and abuse.
From interviews with community-dwelling elders in Boston, Pillemer and Finkelhor estimated that yearly in Massachusetts some 3.2 percent of older adults are physically or psychologically abused or neglected by their caregivers (financial and social abuse and self-neglect were not included). Yet only one in every fourteen of these cases came to professional attention in spite of the state's mandatory reporting law. In their survey of nurses and nurses' aides from area nursing homes, Pillemer and Moore found that 36 percent of the staff had seen at least one incident of a resident being physically abused in the previous year, while 81 percent had seen psychological abuse. Most of this mistreatment did not get reported to authorities. Another study, in which older adults were interviewed, found that 7.5 percent of the respondents reported that they had been physically, psychologically, socially, or financially abused since turning sixty-five years of age (Hudson and Carlson, 1998, 1999). If neglect or self-neglect were added, the prevalence rate would be higher.
Tatara conducted a survey to estimate the national incidence of domestic elder mistreatment. Based on data from only twenty-nine states, he estimated that 735,000 elders were victims of abuse or neglect during 1991, while another 842,000 were victims of self-neglect. He also found that only 14.4 percent of these cases of mistreatment were reported to protective services agencies. The National Elder Abuse Incidence Study (Takamura and Golden) included reported and unreported cases of abuse, neglect, and self-neglect. The findings suggested that some 551,011 adults over the age of sixty living in domestic settings (institutional mistreatment was not included) were abused or neglected during 1996, and for every reported case of mistreatment, approximately five went unreported. Neglect was the most common form of mistreatment found, followed by psychological abuse, financial abuse, and physical abuse. As compared to their composition in the older adult population, women were disproportionately represented in all the abuse categories, and men were disproportionately found in the abandoned group. The neglect cases showed a more proportional distribution between men (40 percent) and women (60 percent).
Victim and perpetrator characteristics
Some studies have addressed specific types of elder abuse and/or neglect to identify the characteristics associated with each. The findings from these studies produced three distinct patterns of victim and perpetrator characteristics. Victims of both physical and psychological elder abuse were found to be both men and women who were young-old (sixty-five to seventy-four years), married, more independent in activities of daily living but in poor emotional health with low morale, in troubled marriages, living with others, lacking confidants, and socially isolated. Their perpetrators were often spouses who had histories of mental illness or problems, had abused alcohol, had a recent decline in mental and/or physical health, were dependent on and lived with the victim, and had experienced recent stress. The perpetrators' characteristics and the quality of the abuser-victim relationship were more related to the abuse than the victims' characteristics, which left victims with few resources for dealing with the abuse.
Participants in material abuse, or exploitation, had a different set of characteristics. Victims tended to be unmarried (widowed, divorced, or never married), older women or men who lived alone and had problems with money management and transportation. They lacked adequate social supports or confidants. Health problems, poor morale, and/or depression limited their activities. Their perpetrators tended to be younger, distant relatives or nonrelatives who abused alcohol and had physical or emotional problems. They did not live with the victims but were financially dependent on them. In material abuse, the victims' characteristics seemed to make them vulnerable to perpetrators who could not function independently (Anetzberger, Korbin, and Austin; Pillemer; Podnieks; Wolf, Godkin, and Pillemer).
In contrast to elder abuse, in which perpetrator characteristics seem to be most relevant, the victims' characteristics seem to be most relevant to elder neglect. Based on studies that compared abuse with neglect, neglect victims were more often old-old (eighty years and older), widowed, disabled women who were dependent on caregivers due to poor health and physical and/or mental impairment. Often they lived with the person who neglected them and had few other people in their social networks. The male and female perpetrators were family members and unrelated caregivers who had experienced losses in their own support system, and viewed the elder as the source of stress (Podnieks; Wolf, Godkin, and Pillemer).
Prevention and intervention
Research has yet to adequately address these aspects of elder mistreatment. One of the most established programs serving mistreated elders is the Elder Abuse Project sponsored by the Victim Services Agency at Mt. Sinai Hospital in New York directed by Risa Breckman (Breckman and Adelman). Breckman is also the codirector of the Elder Abuse Training and Resources Center, which provides training, technical assistance, and case consultation services to organizations through out the country. Rosalie Wolf and Karl Pillemer present four of the best practice models—a multidisciplinary case conference team from San Francisco, a volunteer advocacy program from Madison, Wisconsin, a victim support group from New York City, and a master's degree adult protective services track in social work in Hawaii. They also address some of the common problems faced by community agencies that deal with elder mistreatment cases—the fragmented human services system, the resistance and reluctance of victims to accept services, and the shortage of trained personnel.
Effective intervention in elder mistreatment cases is often difficult to accomplish. First and foremost, since many mistreated elders are competent adults they have the right to refuse assistance even when it is obviously needed. Many of them deny that abuse or neglect is occurring or refuse any assistance offered, often due to embarrassment or fear of retaliation. Only when an older adult is ruled mentally incompetent by a court and a guardian is appointed can intervention be instigated without the elder's consent. Second, in many communities the resources needed for intervention are nonexistent or very limited. Sometimes the only option available is to remove the elder from his or her home. Yet both abuse and neglect also occur in rest and nursing homes. So for some elders the treatment is worse than the original problem. Third, the care of mistreated elders typically requires a multidisciplinary team of health care and human services providers who are well trained regarding the needs of older adults and the needs of abused or neglected elders, and who can address their medical, social, psychological, housing, and legal needs. Fourth, since very little research has been done on elder mistreatment intervention, including which strategies produce the most effective and efficient outcomes, practitioners have little evidence-based information to guide them in caring for these elders. Last, funding has been very limited for instituting or maintaining new initiatives for managing mistreatment cases.
Theoretically speaking, the prevention of elder abuse and neglect will require that ageism be eliminated in our society, and that we restore respect for and honor to our older adults. In addition, it will require that we educate everyone about aging, instill the value of people over material objects, and establish the resources needed to provide quality care for our aged members. Empirically speaking we do not yet know how to effectively prevent or intervene in elder abuse or neglect cases. Very little research has been done on these aspects of elder mistreatment, and there is very little outcome or programmatic evaluation data. Therefore, clinical judgment typically guides prevention and intervention. Until sound research addresses these important aspects of elder mistreatment, this will continue to be the case.
Margaret F. Hudson
See also Ageism; Criminal Victimization.
Anetzberger, G. J.; Korbin, J. E.; and Austin, C. C. "Alcoholism and Elder Abuse." Journal of Interpersonal Violence 9 (1994): 184–193.
Breckman, R. S., and Alderman, R. D. Strategies for Helping Victims of Elder Mistreatment. Newbury Park, Calif.: Sage, 1988.
Burston, G. R. "Granny-Battering." British Medical Journal (6 September 1975): 592.
Butler, R. N. Why Survive? Being Old in America. New York: Harper & Row, 1975.
Douglass, R. L., and Noel, C. "A Study of Maltreatment of the Elderly and Other Vulnerable Adults." Final Report to the U.S. Administration on Aging, Department of HEW and the Michigan Department of Social Services. Ann Arbor, Mich.: Institute of Gerontology, University of Michigan, 1980.
Fulmer, T. T., and Gould, C. S. "Assessing Neglect." Abuse, Neglect, and Exploitation of Older Persons. Edited by L. A. Baumhover and S. C. Beal. Baltimore: Health Professionals Press, 1996. Pages 89–99.
Hudson, M. F. "Elder Mistreatment: Current Research." Elder Abuse: Conflict in the Family. Edited by K. A. Pillemer and R. S. Wolf. Dover, Mass.: Auburn House, 1986. Pages 125–166.
Hudson, M. F. "Elder Mistreatment: A Taxonomy with Definitions by Delphi." Journal of Elder Abuse and Neglect 3 (1991): 1–20.
Hudson, M. F., and Carlson, J. R. "Elder Abuse: Expert and Public Perspectives on it's Meaning." Journal of Elder Abuse and Neglect 9 (1998): 77–97.
Hudson, M. F., and Carlson, J. R. "Elder Abuse: Its Meaning to Caucasians, African-Americans, and Native Americans." Understanding Elder Abuse in Minority Populations. Edited by T. Tatara. Washington, D.C.: Taylor and Francis, 1999. Pages 187–204.
O'Malley, H.; Segars, H.; Perez, R.; Mitchell, V.; and Knuepfel, G. M. Elder Abuse in Massachusetts: A Survey of Professionals and Paraprofessionals. Boston, Mass.: Legal Research and Services for the Elderly. 1979.
Pedrick-Cornell, C., and Gelles, R. "Elder Abuse: The Status of Current Knowledge." Family Relations 31 (1982): 457–465.
Phillips, L. R. "Abuse and Neglect of the Frail Elderly at Home: An Explanation of Theoretical Relationships." Journal of Advanced Nursing 8 (1983): 379–392.
Pillemer, K. A. "The Dangers of Dependency: New Findings on Domestic Violence Against the Elderly." Social Problems 33 (1985): 146–158.
Pillemer, K. A., and Finkelhor, D. "The Prevalence of Elder Abuse: A Random Sample Survey." The Gerontologist 28 (1988): 51–57.
Pillemer, K. A., and Moore, D. W. "Abuse Patients in Nursing Homes: Findings from a Survey of Staff." The Gerontologist 29 (1989): 314–320.
Podnieks, E. "National Survey on Abuse of the Elderly in Canada." Journal of Elder Abuse and Neglect 4 (1992): 5–57.
Reinharz, S. "Loving and Hating One's Elders: Twin Themes in Legend and Literature." In Elder Abuse: Conflict in the Family. Edited by K. A. Pillemer and R. S. Wolf. Dover, Mass.: Auburn House, 1986. Pages 25–48.
Stearns, P. J. "Old Age Family Conflict: The Perspective of the Past." In Elder Abuse: Conflict in the Family. Edited by K. A. Pillemer and R. S. Wolf. Dover, Mass.: Auburn House, 1986. Pages 3–24.
Steinmetz, S. K. "The Politics of Aging, Battered Parents." Society (July/August 1978): 54–55.
Steuer, J., and Austin, E. "Family Abuse of the Elderly." Journal of the American Geriatrics Society 28 (1980): 372–376.
Sumner, W. G. Folkways: A Study of the Sociological Importance of Usage, Manners, Customs, Mores, and Morals. New York: The New American Library, 1960.
Tatara, T. "Understanding the Nature and Scope of Domestic Elder Abuse with the Use of State Aggregate Data: Summaries of Key Findings of a National Survey of State APS and Aging Agencies." Journal of Elder Abuse and Neglect 5 (1993): 35–37.
Takamura, J. C., and Golden, O. The National Elder Abuse Incidence Study: Final Report. Washington, D.C.: National Center on Elder Abuse, 1998.
Wolf, R. S. "Major Findings From the Three Model Projects on Elder Abuse." In Elder Abuse: Conflict in the Family. Edited by K. A. Pillemer and R. S. Wolf. Dover, Mass.: Auburn House, 1986. Pages 218–238.
Wolf, R. S.; Godkin, M. A.; and Pillemer, K. A. Elder Abuse and Neglect: Final Report from Three Model Projects. Worcester, Mass.: University Center on Aging, University of Massachusetts Medical Center, 1984.
Wolf, R. S., and Pillemer, K. A. "What's New in Elder Abuse Programming? Four Bright Ideas." The Gerontologist 34 (1994): 126–129.
See Elder abuse and Neglect
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Adult Protective Services
ADULT PROTECTIVE SERVICES
Adult protective services represents the constellation of interventions used to promote safety and well-being for older persons (or other vulnerable adults) whose health or circumstances subject them to harm or threat of harm. Protective services have evolved since their origins, with current focus on elder abuse broadly defined. Most of the work, however, is directed at the needs of older persons suffering from self-neglect or neglect by a caregiver.
All states have laws mandating the protection of vulnerable older persons. Law implementation is handled by public departments of social services or state units on aging. These agencies function in four major ways to provide adult protective services: (1) receive and investigate reports or referrals; (2) assess client status and service needs; (3) arrange and coordinate or offer services to prevent or treat harm; and (4) seek legal intervention in the form of surrogate decision-making authority for the incapacitated older person or criminal penalty for the abuser, if indicated.
The evolution of adult protective services is both long and complicated. The original protection of adults was narrowly confined to legal intervention. It grew out of concern for the property of mentally incapacitated persons.
Adult protection began with the Law of Twelve Tables, established nearly twenty-five hundred years ago in Rome under the reign of Cicero. This law provided family surrogates with the right to manage the property of adults with severe mental illness. Fourteenth-century English common law gave the king responsibility for handling the property of those without the capacity to reason. Three hundred years later, colonial America adopted a policy of a protective nature.
Prior to the twentieth century the primary means of protecting older Americans was through institutional placement or guardianship appointment. Public benefits expanded in the 1950s enabling more older persons to reside in the community. As the numbers of older persons who lived outside of institutions grew, often without nearby family members, it became apparent that many were unable to provide for their own care or protection without assistance.
Discussions on the need for adult protective services began occurring nationally among such organizations as the Social Security Administration, Veterans Administration, and American Public Welfare Association. Emerging from these discussions were two important forums: the 1960 Arden House Conference on Aging and the 1963 National Council on the Aging's National Seminar on Protective Services for Older People. The latter led to the first definitive book on the subject, Guardianship and Protective Services for Older People by Gertrude Hall and Geneva Mathiasen.
The conferences served to define protective services and stimulate communities to develop related programs. In addition, during the late 1960s, seven research and demonstration projects in adult protective services were conducted in such places as Cleveland, Chicago, and San Diego. Their results suggested: (1) protective clients are those adults with reduced mental or physical capabilities who could not protect themselves or their interests; (2) between 7 and 20 percent of older persons are in need of protective services; (3) the concept of protective services must include access to a wide range of services and potential use of legal authority; and (4) protective services should be provided through a single auspice with a generous and flexible budget as well as the availability of multiple professional disciplines, with social work assuming the leadership role in case consultation.
Evaluation of the demonstration projects made adult protective services a subject of national concern. The findings suggested that few cases were closed because of successful intervention. Moreover, those findings from the Cleveland project at the Benjamin Rose Institute indicated that protective services increased the likelihood of institutionalization and the possible risk of death.
Nevertheless, the conferences and demonstration projects provided a momentum for adult protective services expansion during the early 1970s. This momentum was fueled by passage of Title XX of the Social Security Act in 1974, which provided funding for states to create and enlarge adult protective services as one of only two universal public welfare programs.
The discontent arising out of the demonstration projects grew stronger during the mid-to-late 1970s as a result of three factors: (1) the civil rights movement's concern that protective services abridged individual liberties; (2) the voices of various scholars, including law professor John Regan, on ethical dilemmas associated with protective intervention; and (3) the preference of social workers in public agencies to work with children rather than adults.
It may seem curious that adult protective services spread in light of negative program evaluation results and ethical concerns arising from the demonstration projects. There are at least two likely explanations for this. First, the spread of adult protective services occurred within the public sector while many of the demonstration projects took place within the voluntary sector. Because of differences between the two sectors, it was possible to infer that negative evaluation findings from one did not necessarily reflect upon the other. Second, a few states, such as Wisconsin and the Carolinas, were early leaders in adult protective services. They either obtained federal demonstration project grants or secured local public funding to run their own adult protective services programs. As a result, they helped to interest other states in adult protective services. However, most other states developed "protective services to qualify for Federal funds under title XX" (U.S. Senate Special Committee on Aging, pp. 10–11).
There were few publications on adult protective services during the late 1970s. John Regan and Georgia Singer presented Congress with a working paper on the topic, which included proposed model legislation. By 1980, twenty-five states had adopted some type of adult protective services law. Moreover, about as many had legislation pending or in draft.
It was at this time that the evolution of adult protective services detoured slightly, embracing elder abuse as the focus for intervention. The effect of the departure reestablished direction and offered legitimacy to protective services once again.
Characteristics on the part of adult protective services made elder abuse an easy problem area to embrace. First, the history of protective intervention always included concern for abuse, neglect, and exploitation. In addition, protective services has shown an ability to expand its targeted population when called upon to do so. Finally, the legal authority interest of protective services is mirrored in the potential needs of abused elders.
Elder abuse emerged as a subject of scholarly concern in the late 1970s and as a publicly recognized problem affecting older Americans during the 1980s. Although it has no universally accepted definition, generally elder abuse is regarded as a broad concept that has three basic categories: domestic elder abuse, institutional elder abuse, and self-neglect or self-abuse. Domestic elder abuse is inflicted by someone who has a special relationship with the older person, such as a family member. Institutional elder abuse occurs in residential facilities, like nursing homes. The various forms of elder abuse include physical abuse, sexual abuse, emotional abuse, neglect, and financial exploitation.
Adult protective services begins the new millennium reflecting both its historic base and recent influences. Without a federally enforced model, states developed their own laws, regulations, and service delivery systems. As a result, protective services vary across the country. This diversity is particularly evident in problem definition, program scope, services provided, state funding appropriated, and staff credentials. Nonetheless, nationwide adult protective services show notable consistency in their general approach and philosophical underpinnings.
Typically adult protective services are provided by public service agencies. Occasionally the responsibility is shared with private nonprofit organizations as well, usually through contract or formal agreement. Social work remains the dominant discipline involved in protective services. However, interdisciplinary and interagency coordination is routine, especially with health care, law enforcement, and since the early 1990s, domestic violence programming. Seventy percent of adult protective services laws give a single agency authority for investigating abuse and neglect reports of victims in both domestic and institutional settings. Sometimes the investigation is done in cooperation with long-term care ombudsman or other public agencies.
Ninety percent of states provide protective services to adults under age sixty, but 70 percent of adult protective services cases involve older persons as victims. Although the definitions for problems targeted by protective services differ by state law, everywhere the intent is to address forms of elder abuse, with the following forms covered by 85 percent or more states: physical abuse, financial exploitation, physical neglect, sexual abuse, self-neglect, and emotional abuse. Nearly 60 percent of reports received by protective services involve self-neglect or neglect by a caregiver. Twenty-four percent concern abuse, and just 12 percent represent exploitation.
Funding for adult protective services comes from various sources, including the Social Services Block Grant (descendant of Title XX), Older Americans Act, and state and local revenues. States differ in the scope of protective services, but certain activities are standard, including: report receipt, investigation, and substantiation; risk assessment and client evaluation; care planning, case management, service monitoring, and client advocacy; referral or provision of emergency, supportive, rehabilitative, or preventative services; possible use of legal intervention; and removal of the victim or perpetrator from the home, if needed. In addition, all protective services agencies have staff and professional training, public awareness, and data collection functions.
The principles of adult protective services emphasize individual autonomy above all else. This means that when intervening with adults freedom is more important than safety. Autonomy is never compromised simply because older adults live under circumstances of risk or danger. Unless determined incompetent or incapacitated, or infringing on the rights of others, they are supported in their choice of lifestyle. This perspective is in fundamental contrast with protective services during the 1960s and early 1970s, which was more paternalistic in nature. Other important principles of adult protective services include: self-determination, participation of the adult in decision making, use of least restrictive service alternatives, primacy of the adult in care planning, ensuring confidentiality, and avoidance of causing harm or placing blame.
Issues and trends
Adult protective services have a long history of controversy and periods of unpopularity with the public. This pattern is no less true in the twenty-first century. Moreover, its sources remain the same as those delineated by Mildred Barry in her remarks at the 1963 Arden House Seminar on Protective Services for Older People: "One of our major problems in this field of protective care has been that our goals have not been clear, nor generally acceptable; nor the problem clearly defined, nor its extent and complexity known; nor have there been norms or standards upon which to base program objectives" (Barry, 1963, p. 1).
At the start of the new millennium adult protective services still suffer from vagueness of problem definition as evident both in law and through research. There is no consensus on the meaning of elder abuse as the target for protective intervention. Consequently, state laws and research studies differ in the definitions they use, making generalizations across jurisdictions or study findings very difficult. Also, without national prevalence data, it remains impossible to know the scope of the problem it addresses. Although national forums, including workshops held by the National Institute on Aging and National Center on Elder Abuse, have prioritized initiatives in these areas, they have yet to occur. Moreover, public skepticism regarding protective services continues to rest on questions surrounding its effectiveness along with ethical dilemmas that accompany its implementation, such as the appropriateness of mandatory reporting or the use of costly interventions for older persons whose situations represent repeated abuse or neglect.
Evaluative research on adult protective services since the 1970s is rare. Reason for case closure remains the primary outcome measure, although some states are employing risk assessment instruments to standardize it. An analysis of Illinois protective services clients indicated significant movement to low-risk status at case closure for the majority of cases. Among high-risk clients, the reasons usually given for case closure were institutionalization, death, service refusal, or relocation to another community (not unlike findings from the Benjamin Rose Institute in the early 1970s). The Three Models Project on Elder Abuse evaluated various interventions and found public protective services the least effective, in part because they lacked the resources to go beyond simple report receipt and investigation. In fact, adult protective services in most states are inadequately funded, particularly due to cuts and shifting in federal Social Services Block Grant revenues beginning in the 1980s.
A growing older population and increasing reports of elder abuse in both domestic and institutional settings have led to adult protective services becoming an established part of public welfare systems nationwide in spite of the controversy and skepticism that continue to plague them. Since the late 1980s there also has been a growth in professionalism among protective services workers, largely because of training opportunities and credentialing in some locales. Furthermore, networking through such organizations as the National Association of Adult Protective Services Administrators has helped decrease the historic isolation of protective services workers, improve protective standards, and enhance the knowledge base of the field.
Georgia J. Anetzberger
See also Autonomy; Elder Abuse and Neglect; Guardianship; Social Services.
Anetzberger, G. J. "Protective Services and Long-Term Care." In Matching People with Services in Long-Term Care. Edited by Z. Harel and R. E. Dunkle. New York: Springer, 1995. Pages 261–281.
Barry, M. C. "Responsibility of the Social Welfare Profession in Providing Guardianship and Protecting Services." Paper presented at the Arden House Seminar on Protective Services for Older People, Harriman, New York, 10–15 March 1963.
Bergeron, L. R. "Decision-Making and Adult Protective Services Workers: Identifying Critical Factors." Journal of Elder Abuse & Neglect 10, nos. 3/4 (1999): 87–113.
Blenkner, M.; Bloom, M.; Wasser, E.; and Nielson, M. "Protective Services for Older People: Findings from the Benjamin Rose Institute Study." Social Casework 52, no. 8 (1971): 483–522.
Burr, J. J. Protective Services for Adults: A Guide to Exemplary Practice in States Providing Protective Services to Adults in OHDS Programs. Washington, D.C.: U.S. Department of Health and Human Services, Office of Human Development Services, 1982.
Byers, B., and Hendricks, J. E., eds. Adult Protective Services: Research and Practice. Springfield, Ill.: Charles C. Thomas, 1993.
Callender, W. D., Jr. Improving Protective Services for Older Americans: A National Guide Series. Portland, Me.: University of Southern Maine, Center for Research and Advanced Study, 1982.
Ferguson, E. J. Protecting the Vulnerable Adult: A Perspective on Policy and Program Issues in Adult Protective Services. Ann Arbor, Mich.: The University of Michigan–Wayne State University, The Institute of Gerontology, 1978.
Goodrich, C. S. "Results of a National Survey of State Protective Services Programs: Assessing Risk and Defining Victim Outcomes." Journal of Elder Abuse & Neglect 9, no. 1 (1997): 69–86.
Mixson, P. M. "An Adult Protective Services Perspective." Journal of Elder Abuse & Neglect 7, nos. 2/3 (1995): 69–87.
Otto, J. M. "The Role of Adult Protective Services in Addressing Abuse." Generations 24, no. 11 (2000): 33–38.
Reynolds, S. L. "Shedding New Light on Old Dilemmas: A Critical Approach to Protective Interventions." Journal of Ethics, Law, and Aging 1, no. 2 (1995): 107–119.
Tatara, T. An Analysis of State Laws Addressing Elder Abuse, Neglect, and Exploitation. Washington, D.C.: National Center on Elder Abuse, 1995.
Tatara, T. Elder Abuse: Questions and Answers, 6th ed. Washington, D.C.: National Center on Elder Abuse, 1996.
U.S. Senate Special Committee on Aging. Protective Services for the Elderly: A Working Paper. Washington, D.C.: U.S. Government Printing Office, 1977.
Wolf, R. S. "Major Findings from Three Model Projects on Elderly Abuse." In Elder Abuse: Conflict in the Family. Edited by K. A. Pillemer and R. S. Wolf. Dover, Mass.: Auburn House, 1986. Pages 218–238.
Zborowsky, E. "Developments in Protective Services: A Challenge for Social Workers." Journal of Gerontological Social Work 8, nos. 3/4 (1985): 71–83.
"Adult Protective Services." Encyclopedia of Aging. . Encyclopedia.com. (February 23, 2017). http://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/adult-protective-services
"Adult Protective Services." Encyclopedia of Aging. . Retrieved February 23, 2017 from Encyclopedia.com: http://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/adult-protective-services
Elder abuse is a general term used to describe harmful acts toward an elderly adult, such as physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, and neglect, including self-neglect.
Results from the National Elder Abuse Incidence Study, funded in part by the Administration on Aging, suggest that over 500,000 people 60 years of age and older are abused or neglected each year in the United States. It was also found that four times as many incidents of abuse, neglect, or self-neglect are never reported, causing researchers to estimate that as many as two million elderly persons in the United States are abused each year. In 90% of the cases, the abusers were found to be family members and most often were the adult children or spouses of those abused. In addition, equal numbers of men and women have been identified as the abusers. However, women, especially those over 80 years of age, tend to be victimized more than men.
Elder abuse can take place anywhere, but the two main settings addressed by law are domestic settings, such as the elder's home or the caregiver's home, and institutional settings, such as a nursing home or group home. In general, there are five basic types of elderly abuse: physical, sexual, emotional or psychological, financial, and neglect. Data from National Center on Elder Abuse indicates that more than half of the cases reported involve some kind of neglect, whereas 1 in 7 cases involve physical abuse. It is considered neglect when a caretaker deprives an elderly person of the necessary care needed in order to avoid physical or mental harm. Sometimes the behavior of an elderly person threatens his or her own health; in those cases, the abuse is called self-neglect. Physical abuse refers to physical force that causes bodily harm to an elderly person, such as slapping, pushing, kicking, pinching, or burning.
About 1 in 8 cases of elderly abuse involve some form of financial exploitation, which is defined as the use of an elderly person's resources without his or her consent. The National Center on Elder Abuse defines emotional and psychological abuse of a senior as causing anguish, pain, or distress through verbal or nonverbal acts, such as verbal assaults, insults, intimidation, and humiliation, for example. Isolating elderly persons from their friends and family as well as giving them the silent treatment are two other forms of emotional and psychological abuse. Any kind of non-consensual sexual contact with an elderly person that takes place without his or her consent is considered sexual abuse.
Causes and symptoms
Elder abuse is a complex problem that can be caused by many factors. According to the National Center on Elder Abuse, social isolation and mental impairment are two factors of elder abuse. Studies show that people advanced in years, such as in their eighties, with a high level of frailty and dependency are more likely to be victims of elder abuse than people who are younger and better equipped to stand up for themselves. Because spouses make up a large percentage of elder abusers, at least 40% statistically, some research has been done in the area, which shows that a pattern of domestic violence is associated with many of the cases. The risk of elder abuse appears to be especially high when adult children live with their elderly parents for financial reasons or because they have personal problems, such as drug dependency or mental illness. Some experts have speculated that elderly people living in rural areas with their caretakers may have a higher risk of being abused than city dwellers. The idea behind this theory is that the opportunity exists for the abuse to occur, but there is less likelihood that the abuser will be caught. More research in this very important area is needed in order to illuminate the relationship between these factors.
The National Center on Elder Abuse identifies the following as signs of elder abuse:
- Bruises, pressure marks, broken bones, abrasions, and burns may indicate physical abuse or neglect.
- Unexplained withdrawal from normal activities and unusual depression may be indicators of emotional abuse.
- Bruises around the breasts or genital area, as well as unexplained bleeding around the genital area, may be signs of sexual abuse.
- Large withdrawals of money from an elder's bank account, sudden changes in a will, and the sudden disappearance of valuable items may be indications of financial exploitation.
- Bedsores, poor hygiene, unsanitary living conditions, and unattended medical needs may be signs of neglect.
- Failure to take necessary medicines, leaving a burning stove unattended, poor hygiene, confusion, unexplained weight loss, and dehydration may all be signs of self-neglect.
Diagnosis and Treatment
The National Committee for the Prevention of Elder Abuse notes that Adult Protective Services (APS) caseworkers are often on the front lines when it comes to elderly abuse. People being abused or those who believe abuse is taking place can turn to their local APS office for help. The APS routinely screens calls, keeps all information confidential, and, if necessary, sends a caseworker out to conduct an investigation. In the event that a crisis intervention is needed, the APS caseworker can arrange for any necessary emergency treatment. If it is unclear whether elder abuse has taken place, the APS caseworker can serve as a liaison between the elderly person and other community agencies.
According to the National Committee for the Prevention of Elder Abuse, "professionals in the field of aging are often the first to discover signs of elder abuse." Providing encouragement and advice, they play a critical role in educating others with regard to the needs of the elderly. They not only provide valuable support to the victims of abuse, but they also monitor high-risk situations and gather important information that can help validate that abuse has taken place.
Some people might think that a person who has cognitive impairment might be unable to describe mistreatment; however, that is not the case. In fact, guidelines set by the American Medical Association call for "routine questions about abuse and neglect even among patients with cognitive impairment in order to improve the identification of cases and implement appropriate treatment and referral." Rather than an inability to describe mistreatment, what might stop an elderly person from reporting abuse is a sense of embarrassment or fear of retaliation. To complicate matters, differences exist among cultural groups regarding what defines abuse.
Therefore, most states have established laws that define elder abuse and require health care providers to report any cases they encounter with penalties attached for failing to do so. Indeed, statistics show that health care providers, for example, report almost 25% of the known cases of elder abuse. Therefore, physicians play a very important role in identifying and treating elders who have been abused. And yet, in an article published by the Journal of the American Geriatrics Society, Dr. Conlin pointed out that only 1 of every 13 cases of elder abuse are reported by physicians. There may be several reasons for this. In some cases, the problem may simply go unnoticed, especially if the physician has no obvious reason to suspect any wrongdoing. In other cases, the patient may hide or deny the problem.
In recent years, much media attention has been focused on elderly abuse that takes place in institutional settings. Anyone who believes that a loved one is being abused while in a nursing home or other institutional setting should contact the authorities for assistance immediately.
The mortality rate of an elderly person who has been mistreated is higher than the mortality rate of an elderly person who has not experienced abuse. Nonetheless, numerous success stories exist regarding successful interventions. Social workers and health care professionals, as well as concerned citizens from a variety of backgrounds, have played a key role in identifying and obtaining treatment for abused elders.
Planning for the future is one of the best ways to avoid elder abuse. Consider a variety of retirement options, ones that will encourage safety as well as independence. It is important to stay active in the community. Avoiding isolation minimizes the likelihood that abuse will occur. Seek professional counsel when necessary; it is important for everyone to know their rights and to be advocates on their own behalf.
Clarke, M. E., Pierson, W. "Management of elder abuse in the emergency department." Emergency Medical Clinics of North America 17 (1999): 631-644.
Conlin, M. "Silent suffering: a case study of elder abuse and neglect." Journal of the American Geriatrics Society 43 (1995): 1303-1308.
Lachs, M. S., Willimas, C. S., O'Brien, S., Pillemer, K. A., Charlson, M. E. "The mortality of elderly mistreatment." Journal of the American Medical Association 280 (1998): 429-432.
Administration on Aging "Elder Rights & Resources. Elder Abuse." Administration on Aging 10 December 2004 Administration on Aging, Department of Health and Human Services. 1 April 2005 〈http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/Elder_Abuse_pf.asp〉.
American Medical Association "Featured CSA Report: AMA Data on Violence Between Intimates (I-00): Elder Abuse." American Medical Association January 2005 American Medical Association. 1 April 2005 〈http://www.ama-assn.org/ama/pub/category/13577.html〉.
National Center on Elder Abuse "The Basics: Major Types of Elder Abuse." National Center on Elder Abuse 15 May 2003 National Center on Elder Abuse. 1 April 2005 〈http://www.elderabusecenter.org/〉.
National Center on Elder Abuse "Elder Abuse: Frequently Asked questions." National Center on Elder Abuse 23 March 2005 National Center on Elder Abuse. 1 April 2005 〈http://www.elderabusecenter.org/〉.
National Committee for the Prevention of Elder Abuse "The Role of Professionals and Concerned Citizens." National Committee for the Prevention of Elder Abuse March 2003 National Committee for the Prevention of Elder Abuse. 1 April 2005 〈http://www.elderabusecenter.org/〉.
"Elder Abuse." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (February 23, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/elder-abuse
"Elder Abuse." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved February 23, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/elder-abuse
Although conflict in families has been a consistent theme in world literature since ancient times, elder abuse did not surface as a social problem until the mid-1970s, first identified in British literature, followed soon after in the United States and Canada. During the next decade several European countries and Australia began publishing reports on elder mistreatment. By the 1990s elder abuse research and programs, although still limited, were underway in many developed nations and emerging in developing countries as well.
Elder abuse has been used as an all-inclusive term representing types of abusive behavior against the elderly, or it can refer to a specific act of physical violence. Most experts agree that elder abuse can be an act of commission (abuse) or omission (neglect), intentional or unintentional, and of one of more types: physical, psychological (emotional and/or verbal aggression), and financial abuse and neglect that results in unnecessary suffering, injury, pain, loss, and/or violation of human rights and decreased quality of life. Whether the behavior is labelled as abusive, neglectful, or exploitative may depend on the frequency of the mistreatment, as well as the duration, intensity, severity, consequences, and cultural context. Some researchers have questioned the legal and professional basis of the current definitions and suggest that it is the older person's perception of the behavior that is meaningful. Others have noted the importance of cultural traditions in defining what is acceptable and unacceptable behavior.
An initial effort to elicit information about elder abuse directly from older persons in three historically "black" South African townships showed that in addition to the typical western schema of physical, verbal, financial, sexual, abuse and neglect, the focus group participants added loss of respect for elders, accusations of witchcraft, and systemic abuse (marginalization of older persons by the government).
So far, prevalence studies have been restricted to the developed world. Five community-based prevalence surveys conducted in five countries using different methods of data collection reported rates that ranged between 4 to 6 percent of the older population although the proportion of abuse types among the five varied. Two were national in scope, Canada and the UK (Podnieks 1992; Ogg and Bennett 1992); a third encompassed the retired population of a small Finnish town (Kivelä et al. 1992), and the other two utilized representative samples of cities in the United States (Boston) (Pillemer and Finkelhor 1988) and the Netherlands (Amsterdam) (Comijs et al. 1998). In the U.S. and Canadian studies, men and women were apt to be mistreated equally; in the Finnish and Dutch surveys, female victims outnumbered males. A later national Canadian survey on family violence reported older men (9%) were more likely than older women (6%) to report being victims of emotional or financial abuse (Bunge and Locke 2000). No systematic collection of abuse statistics or prevalence surveys has been conducted in the developing world but crime records, journalistic reports, social welfare records, and small scale studies contain evidence that mistreatment of elders is occurring.
Theoretical Explanations and Risk Factors
To explain the causes of elder abuse, some researchers in the developed countries have viewed it as a problem of an overburdened caregiver (situational model), a mentally disturbed abuser (intra-individual dynamics), or a dependent perpetrator and dependent victim (exchange theory). Others have used learned behavior (social learning theory), the imbalance of power within relationships (feminist theory), the marginalization of elders (political economy theory), or a lack of fit between the organism and the environment (ecological theory).
Without data to support the theories, the focus has been on determining the risk-factors or characteristics that increase the probability of victimization but are not necessarily causal agents. With the limited data available, the most likely risk factors seem to be (a) victim-perpetrator dependency, (b) perpetrator deviance, (c) victim disability, (d) care-giver stress, and (e) social isolation. While the developed nations have emphasized the individual and interpersonal attributes, the developing nations have given weight to societal and cultural factors, including poverty, ageism, sexism, and violence.
Consequences of Mistreatment
Few empirical studies have been conducted to determine the consequences of mistreatment on the physical and mental health of older victims, in part because of the difficulty in separating the effects of normal aging and chronic diseases from abusive behavior. To date, one study has reported the impact on physical status. Using two existing data bases (health survey data from a representative sample of 2,812 elders in a U.S. city and reports to the adult protective service agency [APS] collected over a nine year period), researchers found that those individuals who had been reported to APS and who were physically abused or neglected had a mortality rate three times those who had not been reported. After controlling for the possible factors that might affect mortality (e.g., age, gender, income, functional and cognitive status, diagnosis, and social supports) and finding no significant relationships, they speculated that mistreatment causes extreme interpersonal stress that may confer an additional death risk (Lachs et al. 1998).
Several studies have reported in an abuse sample a higher proportion of older victims with depression or psychological distress than in a non-abuse sample. Since these were cross-sectional in design, there is no way to know whether the condition was an antecedent or consequence of the abuse (Bristowe and Collins 1989; Phillips 1983; Pillemer and Prescott 1989; Comijs et al. 1999) Other suggested symptomatology associated with these cases include feelings of learned helplessness, alienation, guilt, shame, fear, anxiety, denial, and posttraumatic stress syndrome.
Generally, countries delivering services to abused, neglected, and exploited elders have done so through existing health and social service systems. Because of the complexity of the cases, which often involve medical, legal, ethical, psychological, financial, criminal, and environmental issues, guidelines and protocols are used to assist the workers, and special training is made available to them. Multidisciplinary consulting teams are called upon to assist in planning the care. Telephone "helplines" to take reports are often the first component of an elder abuse system. Since much of elder abuse is spouse abuse, there is growing interest in providing services modeled after those developed for younger battered women, such as emergency shelters, support groups, the use of law enforcement, and the criminal justice system. Except for the United States, Israel, and four Canadian provinces, most countries have not passed specific elder abuse legislation but rely on civil rights, family violence, mental health, property rights, and criminal statutes to address the problem.
That family members can be abusive or neglectful toward their elders even in societies that emphasize filial piety and family harmony came as a revelation to the world. A quarter century of efforts to deal with the problem in the United States has built an infrastructure based on a model in which protective service personnel respond to reports of abuse by conducting investigations and devising follow-up treatment plans, but primary prevention techniques have received little attention in other developed countries. Families in the developing world face still more severe challenges, including forced emigration, economic recession, and changing characteristics. The process of industrialization has eroded long-standing patterns of interdependence between the generations, producing material and emotional hardships for elders. However, with increasing interest around the globe in human rights, gender equality, and violence prevention, the future augers well for bringing an end to this age old problem.
See also:Caregiving: Informal; Dementia; Elders; Filial Responsibility; Intergenerational Relations; Later Life Families; Respite Care: Adult; Spouse Abuse: Prevalence; Spouse Abuse: Theoretical Explanations; Stress; Substitute Caregivers
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rosalie s. wolf
"Elder Abuse." International Encyclopedia of Marriage and Family. . Encyclopedia.com. (February 23, 2017). http://www.encyclopedia.com/reference/encyclopedias-almanacs-transcripts-and-maps/elder-abuse
"Elder Abuse." International Encyclopedia of Marriage and Family. . Retrieved February 23, 2017 from Encyclopedia.com: http://www.encyclopedia.com/reference/encyclopedias-almanacs-transcripts-and-maps/elder-abuse