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II. Defining Elder Abuse
A. Elder Abuse as a Violation of the Criminal Law
B. Elder Abuse as a Violation of Regulatory Law
C. Elder Abuse as a Social Construction
D. Elder Abuse as Social Harm
1. Physical Abuse
2. Financial Abuse
3. Sexual Abuse
6. Emotional Abuse
III. Identifying Elder Abuse
IV. Explaining Elder Abuse
Since the 1970s, elder abuse has been increasingly recognized as a problem across the world. Attention from researchers first surfaced when Baker (1975) discussed the concept of “granny battering” in British medical journals in the mid-1970s. In the United States, interest paralleled a series of political actions, media exposures, and research reports. In 1979, the House Select Committee on Aging held a hearing called “The Hidden Problem.” Around the same time, an episode of Quincy, a late-1970s TV drama series, depicted a case of elder abuse. Katz (1990) argues that the Quincy episode built support for the elder abuse agenda and contributed to public demands for changes in state and federal statutes. Also, The Battered Elder Syndrome was published by Block and Sinnott (1979) around this time, giving increased attention to problems of abuse encountered by older adults.
Since that time, many have accepted that elder abuse is a problem that needs to be addressed by different disciplines and practitioners. Most agree that the best response to elder abuse involves what is called a “multidisciplinary” or “integrated” response. This means that several different agencies are involved in the prevention of and response to elder abuse. To promote a full understanding of the integrated response to elder abuse, this research paper addresses the following areas: defining elder abuse, identifying elder abuse, and explaining elder abuse.
II. Defining Elder Abuse
Elder abuse is an underdeveloped area of study. Part of the problem inhibiting the development of research in this area hinges on the lack of uniform definitions of elder about. Generally speaking, elder abuse can be defined in several ways:
- Elder abuse as a violation of the criminal law
- Elder abuse as a violation of regulatory law
- Elder abuse as a social construction
- Elder abuse as social harm
A. Elder Abuse as a Violation of the Criminal Law
In considering elder abuse as a violation of the criminal law, one can evaluate how elder abuse is criminally defined across the United States. The criminalization of elder abuse is a relatively recent phenomenon. This criminalization involves a surge of criminal justice activity in an effort to apply criminal laws in the area of elder abuse. Criminal laws related to elder abuse can be characterized in three ways. These include (1) laws penalizing offenders for crimes against older individuals, (2) laws specific to the treatment of older persons, and (3) general criminal statutes. First, laws that penalize offenders for crimes against older persons are criminal statutes that call for increased penalties for crimes against persons over a certain age. Known as penalty enhancement laws, they provide for stiffer penalties for individuals who victimize older persons. For example, if an offender robs a 30-year-old victim, the recommended penalty might be 5 years in prison. However, if that offender robs an 80-year-old victim, the penalty might be 8 years.
Second, criminal laws regarding the treatment of older persons include laws that specifically apply to this population. Failure to provide care to an older person is one example. Another example involves states that have specific laws covering crimes occurring in nursing homes or other long-term care settings. For instance, stealing from a vulnerable adult might be classified as “adult abuse” or some other phrase in some states’ statutes.
Third, general criminal statutes apply to elder abuse when states do not have specific laws related to elder abuse. If a grandchild abuses his grandparent, this would be called criminal assault in states where elder abuse laws are not provided. Consider as another example a case where a prosecutor prosecuted a contractor under the burglary criminal statutes when he defrauded an older woman. The prosecutor successfully argued that the contractor entered the woman’s home with the intent to steal from her. Entering a residence with the intention to steal is the basic definition of burglary, and thus the general criminal statute was applied.
There is tremendous variation in the way that states criminally define laws related to elder abuse. According to Lori Stiegel (1995), an elder abuse expert who works for the American Bar Association, the complexity and breadth of the criminal law with regard to elder abuse are evidenced by the fact that the state laws vary in at least six important ways: (1) their definitions of elderly, (2) their definitions of abuse, (3) whether the abuse is classified as criminal or civil, (4) their standards for reporting the abuse, (5) how the abuse should be investigated, and (6) their recommended sanctions for the abuse.
B. Elder Abuse as a Violation of Regulatory Law
Elder abuse can also be conceptualized as a violation of regulatory law. Indeed, there may be instances when an institution or agency harms an older person. In these cases, it is rare that criminal statutes are used to govern or respond to the harmful behavior; instead, regulations developed by state and federal governments are used to guide the response to the abusive activities. As an illustration, consider that an inordinate number of regulations have been developed to govern the way nursing homes serve their residents. Routinely, licensing investigators visit nursing homes to determine whether the institutions are adhering to regulations. Among the common violations cited against nursing homes are that they fail to adhere to the following regulations:
- Make an adequate comprehensive assessment of resident’s needs.
- Store, prepare, distribute, and serve food under sanitary conditions.
- Develop a comprehensive care plan, with measurable goals and timetables, to meet resident’s medical, nursing, and mental and psychosocial needs.
- Ensure that the resident environment remains as free of accident hazards as possible.
- Promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.
Note that when nursing homes commit these actions, they are not criminally prosecuted; instead, because the actions are regulatory violations, the institutions are issued a warning or fined if the actions are not reconciled.
C. Elder Abuse as a Social Construction
Some have also argued that elder abuse is a socially constructed crime. What this means is that the actions are illegal because society says they are illegal. Consider elder sexual abuse. It is illegal for a caregiver (who is unrelated to the elder) to have sexual relations with the care recipient. However, if the individuals were of the age of consent and under the age determined to be elderly, such relations would not be considered as illegal.
There are other ways to view elder abuse as a social construction. For example, certainly the behaviors that are now labeled elder abuse have occurred throughout time. In fact, some of Shakespeare’s writings have included behaviors that are now cited as elder abuse. During Shakespeare’s time, the phrase “elder abuse” had not yet been socially constructed. Today, the phrase is used to describe a range of behaviors that were defined in different ways in the past.
Some have criticized those who have been instrumental in promoting the study of elder abuse as a separate field. Social scientist Stephen Crystal (1987) argued that the area of study broadly defined the phenomenon of elder abuse so as to increase the number of “elder abuse” victims. This was done, he argued, in order for practitioners to justify their careers and agencies and receive funding and resources for their activities.
D. Elder Abuse as Social Harm
Another way to define elder abuse is as social harm. What this means is that whether the crime is defined in statutes as illegal is insignificant; rather, if an older person is harmed, then elder abuse has occurred. Justifying this approach to understanding elder abuse, in his book Crime and Elder Abuse, criminologist Brian Payne (2006) argues the following:
From this perspective, behaviors that harm older persons can be classified as elder abuse. Such a broad conceptualization includes harmful behaviors at the societal, institutional, and individual levels.
Societal abuses include harmful actions, laws, and policies implemented at the societal level that harm older persons. Institutional abuses include the regulatory violations described above. Individual abuses include a range of behaviors. The most commonly cited forms of individual abuse include the following behaviors:
- Physical abuse
- Financial abuse
- Sexual abuse
- Emotional abuse
The way that each of these behaviors can be defined as elder abuse within a social harm framework is addressed below.
1. Physical Abuse
Physical abuse involves a host of acts that have been committed against elderly persons that range from pinching, slapping, or hitting an older person to committing murder. Five related types of physical abuse have been discussed in the literature: parent abuse, spouse abuse, patient abuse, other violent crimes, and homicides. Parent abuse occurs when an offspring abuses his or her parent. This is among the more commonly reported cases of elder abuse. In these cases, health care professionals or neighbors are the likely reporters, and it is common that the abuser is unemployed and suffering from a drug problem.
Spouse abuse occurs when violence takes place between older persons who are in an intimate relationship. Several patterns have been used to describe elder spouse abuse. Some have noted that it is the result of abuse occurring over the life span. Because abusers do not stop when they become elderly, elder spouse abuse may simply be an indication of a lifetime of violence. Another pattern is that women may become the abusers (after having been victimized by their husbands) once their husbands are physically dependent on them. Also, some experts have noted that elder spouse abuse may occur in second marriages. Difficulty dealing with adult stepchildren, concerns about joint finances, and unfair comparisons to former spouses have been cited as factors contributing to abuse in second marriages. A final pattern is that elder spousal abuse has been attributed to the consequences of dementia.
Patient abuse occurs when a paid care provider physically abuses someone in his or her care. The extent of patient abuse is unknown. Abuse is more commonly attributed to nurse’s aides. Originally, it was believed that such abuse was caused by poor training, difficulties dealing with a stressful work situation, and self-defense against abusive residents. More recently, research by Brian Payne and Randy Gainey (2005) found that a significant proportion of patient abusers were basically predators who had committed prior criminal acts. The need for criminal background checks is being explored by a number of state and federal governments.
Elder physical abuse also includes the range of violent crimes (e.g., robbery, assault, etc.) that can occur at any point during the life course. Robbery is using force or threat of force to steal or attempt to steal another’s property. Assault includes attacks with or without weapons that may or may not result in injury. It seems important to note that the majority of offenders reported in these cases involving older victims were strangers to the victims. The Bureau of Justice Statistics (1994) reports that older violent crime victims “are more likely than younger victims to face assailants who are strangers” and that older robbery victims “are more likely than younger victims to be particularly vulnerable to offenders whom they do not know” (p. 2). Further, findings from the National Crime Victimization Survey (BJS, 1994) show the following results:
- People aged 65 to 74 have a higher victimization rate than those 75 or older.
- Older blacks are more likely to be victimized than older whites.
- Elderly persons with the lowest incomes experience higher rates of violence than elderly with high incomes.
- Separated and divorced elderly persons are more likely to be victims of violent offenses than married elderly persons are.
- Elderly victims of violence are almost twice as likely to be victimized at or near their homes.
Homicides are also committed against the elderly, and it is believed that a high number of elder homicides are misdiagnosed as natural deaths each year. Former homicide investigator Joseph Soos has identified the following five types of homicide committed against elderly persons: (1) murder-for-profit killings, (2) revenge killings, (3) eldercide, (4) gerontophelia, and (5) relief-of-burden killings (cited in Payne, 2006). Murder-for-profit killings occur when individuals kill older persons for their life insurance, inheritance, or other profit. Revenge killings occur when individuals kill older persons out of anger toward the older victim. Eldercide occurs when individuals, typically serial killers, have a fascination with killing older persons. Gerontophelia occurs when individuals kill older persons in order to cover up some other crime. Relief-of-burden killings occur when individuals feel overly stressed about the caregiving experience.
A National Institute of Justice study by Erik Lindbloom and his colleagues (2005) found that four factors in elder deaths often result in referrals to the attorney general’s office for further investigation. These factors included the following:
- Physical condition/quality of care. Specific markers include documented but untreated injuries; undocumented injuries and fractures; multiple, untreated, and/or undocumented pressure sores; medical orders not followed; poor oral care; poor hygiene, and lack of cleanliness of residents; malnourished residents who have no documentation for low weight; bruising on nonambulatory residents; bruising in unusual locations; statements from family concerning adequacy of care; and observations about the level of care for residents with nonattentive family members.
- Facility characteristics. Specific markers include unchanged linens, strong odors (urine, feces), trash cans that have not been emptied, food issues (unclean cafeteria), and documented problems in the past.
- Inconsistencies. Specific markers include inconsistencies between medical records, statements made by staff members, or observations of investigators; inconsistencies in statements among groups interviewed; and inconsistencies between the reported time of death and the condition of the body.
- Staff behaviors. Specific markers include staff members who follow an investigator too closely, lack of knowledge or concern about a resident, unintended or purposeful verbal or nonverbal evasiveness, and a facility’s unwillingness to release medical records (cited in McNamee & Murphy, 2006).
2. Financial Abuse
According to criminologist Brian Payne (2006), four general varieties of elder financial abuse include exploitation by primary contacts, nursing home theft by caregivers, fraud by secondary contacts, and other property crimes by strangers. Exploitation by primary contacts refers to those thefts by individuals who supposedly have a close relationship with the victim (e.g., children, caregivers, other relatives, etc.). Exploitation is defined in various ways, depending on one’s orientation. The exploiter is often a relative of the victim and is in many cases financially dependent on the victim.
One scenario that arises in financial abuse cases is that a time may come when an elderly person must rely on someone else to help with his or her financial matters. The assistance may be limited to providing help paying bills or shopping, or it may be that the older adult will grant power of attorney to a trusted primary contact, thus giving the person the authority to make virtually all financial decisions. As already established, many cases of financial exploitation are those where the victim has placed a great deal of trust in a relative, friend, or caregiver.
Nursing home theft by caregivers occurs when nursing home employees steal from residents. Dianne Harris and Michael Benson (1998) have conducted several studies considering various dynamics related to thefts in nursing homes. Based on their estimates from reported victimizations, they claim that up to 2 million thefts possibly occur in nursing homes each year. Items stolen include jewelry, clothing, and cash. New employees and disgruntled employees tend to be implicated as offenders more often than other types of employees. Nursing home administrators use a variety of strategies in an effort to curtail thefts. Harris and Benson argue that the premeditated nature of nursing home thefts potentially makes these thefts “worse” than physical abuse. In effect, thieves plan thefts, whereas some cases of physical abuse may be unplanned and reactive in nature.
Fraud by secondary contacts includes offenses committed by individuals with whom the older victim did not have a long-lasting, trusting relationship. These offenses include home repair fraud, insurance fraud, medical fraud, confidence games, telemarketing fraud, and phony contests. Home repair fraud occurs when offenders steal from the elderly by either overcharging or failing to appropriately provide services for which they were contracted. Insurance fraud occurs when offenders convince older persons to buy useless or unnecessary insurance policies. Medical fraud occurs when health professionals charge older persons for unnecessary services. Confidence games occur when offenders con older persons out of their money, usually through some get-rich-quick scheme. Telemarketing fraud occurs when offenders contact older persons over the phone and steal from them through the offer of some particular service or product. Finally, phony contests fraud entails situations where offenders convince older persons to engage in some contest that they have absolutely no chance of winning. To be sure, each of these offenses could also target younger persons; however, older persons are overrepresented as victims. They are believed to have more money and to be more trusting, so offenders intentionally seek out older persons at church, Bingo halls, or other places that older persons are known to frequent.
Other property crimes by strangers include the range of property offenses that can target all individuals, such as larceny, burglary, arson, and so on. Like the “other violent offenses,” interesting patterns surround these crimes. Of particular interest are the following estimates from the Bureau of Justice Statistics (1994):
- In 1992, the personal theft and household crime rates among the elderly were the lowest since the NCVS started collecting data in 1972.
- Like the rest of the population, older adults are the least susceptible to violent crimes, but most susceptible to household crimes.
- Those 65 and over are about as likely as younger individuals to be victims of purse snatching and pocket picking.
- Older women are more likely than older men to be victims of personal larceny.
- Elderly black women are the least likely to be victims of personal theft.
- Younger victims of personal theft are less likely to tell the police about the act than elderly victims are.
- Separated or divorced elderly persons are more likely to be victims of personal theft than married elderly persons are.
- Elderly renters are less likely than elderly homeowners to be victims of household crimes.
Other patterns also appear from analysis of NCVS data. For example, among elderly persons, white females are most likely to be victimized by personal theft, followed by white males, black males, and black females. These figures are particularly interesting when compared to rates of violence reported in the official crime statistics. In contrast, among elderly persons, elderly black males have the highest rate of violence, followed by black females, white males, and white females. Thus, elderly whites are more likely to be victims of personal theft, and elderly blacks are more likely to be victims of violent crime.
3. Sexual Abuse
According to the National Center on Elder Abuse (2005), elder sexual abuse is “non-consensual sexual contact of any kind with an elderly person” (National Center on Elder Abuse, 2006, p. 1). Official statistics suggest that older adults are rarely sexually abused (as compared to younger victims). Even so, interviews conducted by elder abuse expert Holly Ramsey-Klawsnik (1991) with Adult Protective Services employees show that most, if not all, individuals working in Adult Protective Services have encountered instances of elder sexual abuse. Ramsey- Klawsnick argues that elderly persons are prime targets of sexual abuse because many are vulnerable and either unwilling or unable to report the abuse. The central premise of her approach to understanding elder sexual abuse is that sexual offenses are more often about power and control, and abusive caregivers find themselves in a position of power. They use sex to maintain the power and subsequently exert even more control over the victim. She further suggests that official statistics underestimate the extent of elder sexual abuse.
Based on this framework, Ramsey-Klawsnick (1999) cites three types of behaviors that are examples of elder sexual abuse. First, hands-off behaviors include activities where the offender does not touch the victim but does things that are sexual in nature that potentially harm the victim. Ramsey-Klawsnick cites “exhibitionism, voyeuristic activity, and forcing an individual to watch pornographic materials” as examples of hands-off behaviors (p. 2). Second, hands-on behaviors involve behaviors where the offender makes contact with the victim. Third, harmful genital practices include “unwarranted, intrusive, and/or painful procedures in caring for the genitals or rectal area” (p. 2).
Neglect is a form of elder abuse that occurs when individuals fail to provide care to a person for whom they are expected to provide care. Some have argued that neglect is the most common form of elder abuse. Experts cite two types of neglect: active and passive. The simplest distinction between the two forms of neglect has to do with intent. In active neglect cases, the offender intends to neglect the care recipient; in passive neglect cases, the caregiver does not intend to commit neglect—the offender often just does not know how to provide care to an older person.
Self-neglect has been described as the most controversial form of elder abuse. It basically refers to instances where individuals fail to provide care to themselves. Technically, it is not criminal in nature. Older persons would never be sent to jail or prison, or placed on probation for that matter, for failing to take their medication, not eating, hoarding goods, or any other self-neglectful behavior. Still, protective services may be called to intervene in situations where self-neglect is believed to be occurring. It is controversial because self-neglect has been regarded, by some, as ageist. That is, if a younger person engages in self-neglectful behaviors, no formal interventions will occur. If an older person engages in these behaviors, however, the individual may be approached by Adult Protective Services for some form of intervention, which in some cases—albeit rarely—may include institutional placement. While it is not criminal behavior, in Family Violence and Criminal Justice: A Life Course Approach, Payne and Gainey (2005) argue that self-neglect is a form of family violence. They suggest that such behavior may be occurring with other forms of abuse. Even if other forms of abuse are not occurring, self-neglect may harm family members who have to witness their loved one not taking care of him- or herself.
6. Emotional Abuse
The National Center on Elder Abuse defines emotional (or psychological) abuse as the “infliction of anguish, pain, or distress through verbal or nonverbal acts” (http://www.ncea.aoa.gov/). Although this is the least commonly reported form of elder abuse, the harm from such abuse can be devastating. The range of behaviors include using derogatory language, calling people names they don’t want to be called, isolating them, not allowing them to choose how to spend their time, and so on. In some instances, emotional abuse may be subtle. Consider a case in which a caregiver never lets a care recipient choose what to watch on television. In other instances, the behavior may be more blatant. Consider a case in which a caregiver arranges furniture so that the care recipient cannot move around as easily, or the caregiver moves pictures of the care recipient’s loved ones so they are out of the view of the care recipient. Such behavior certainly falls within the framework of a social harm approach to defining elder abuse.
III. Identifying Elder Abuse
Estimates from the National Center on Elder Abuse show that a number of different groups are involved in identifying elder abuse. The following estimates show how often different representatives reported suspected elder abuse cases to state reporting systems:
- Health care providers reported 22.5% of elder abuse cases to protective services.
- Family members reported 16% of elder abuse cases to authorities.
- Service providers (including paid and volunteer workers) reported 15% of the cases.
- Friends and family members reported 8% of elder abuse cases to protective services.
- Adult protective services workers reported 6% of cases to authorities.
- Law enforcement officials reported 4.7% of cases to protective services.
- An unrelated caregiver reported elder abuse in 3.3% of cases.
- The victim reported the elder abuse in 3.8% of cases.
Given that just 1 in 25 reports is made by the victim him- or herself, it is imperative that those who are in situations where elder abuse might be present are able to identify the cases. Warning signs are related to types of abuse. One set of warning signs demonstrates the possibility of physical abuse, while other sets of warning signs exist for sexual abuse, neglect, financial abuse, and so on.
The California Department of Justice (2002) classifies warning signs into categories of physical, isolation, and behavioral. Physical warning signs of elder abuse include the following:
- Uncombed or matted hair
- Poor skin condition or hygiene
- Unkempt or dirty appearance
- Patches of hair missing or bleeding scalp
- Any untreated medical condition
- Malnourished or dehydrated
- Foul smelling
- Torn or bloody clothing or undergarments
- Scratches, blisters, lacerations, or marks
- Unexplained bruises or welts
- Burns caused by scalding water, cigarettes, or ropes
- Injuries that are incompatible with explanations
- Any injuries that reflect an outline of an object—for example, a belt, cord, or hand (p. 3)
Isolation warning signs refer to instances when older persons are physically separated from others. Experts suggest that abusers use isolation as a strategy to hide the abuse and promote the victim’s dependence on the abuser. Signs of isolation include the following:
- Family members or caregivers have isolated the elder, restricting the elder’s contact with others, including family, visitors, doctors, clergy, or friends.
- Elder is not given the opportunity to speak freely or have contact with others without the caregiver being present. (California Department of Justice, 2002, p. 4)
Behavioral warning signs refer to behaviors of the elder or caregiver that indicate abuse. Consequences of virtually any form of abuse may result in victims acting or behaving differently. Behavioral warning signs for elder physical abuse include instances when the older victim appears to exhibit the following behaviors:
- Fear to communicate
- Fear in general (California Department of Justice, 2002, p. 5)
A different set of warning signs might arise for other forms of elder abuse. For example, discussing ways that health care professionals can identify financial abuse in Crime in the Home Health Care Field, Brian Payne (2003) suggests that the warning signs of financial abuse include the following:
- Sudden changes in banking practice
- Abrupt changes in a will or other documents
- Abrupt and unexplainable disappearance of money or other assets
- Additional names on elder’s bank signature card
- Poor care provided although adequate resources available
- Previously uninvolved relatives become involved and make claims to assets
- Unpaid bills although funds are available
- Sudden withdrawal from accounts
- Extraordinary interest by others in elderly person’s assets
To be sure, when searching for signs of abuse, individuals should focus on all forms and recognize that it is not their job to determine that elder abuse occurred; instead, it is their job to determine if it might have occurred. Investigators are given the task of substantiating the abuse. As an illustration, the American Medical Association suggests that health care practitioners ask the following questions of vulnerable patients who exhibit risk factors for abuse:
- Does anyone hit you?
- Are you afraid of anyone at home?
- Does anyone take things that don’t belong to you without asking?
- Has anyone ever touched you without your consent?
- Are you alone a lot?
- Does anyone yell at you or threaten you?
If a patient answers yes to any of these questions, it does not necessarily mean that abuse occurred. However, it does mean that abuse might have occurred, and health care professionals or other individuals should report their suspicions to social services.
While signs of elder abuse exist and practitioners are given a set of questions to ask to identify the possibility of abuse, the reality is that elder abuse is drastically underreported. Estimates from the National Center on Elder Abuse suggest that anywhere from 1 in 5 to 1 in 14 cases of elder abuse are reported. To address underreporting and other issues related to elder abuse, Attorney General Janet Reno asked a group of 27 experts to participate in a round table in October 2000. The round table was titled Elder Justice: Medical Forensic Issues Relating to Elder Abuse and Neglect. The panel suggested that elder abuse was unreported and undiagnosed for the following reasons:
- No established signs of elder abuse and neglect. There is a paucity of research identifying what types of bruising, fractures, pressure sores, malnutrition, and dehydration are evidence of potential abuse or neglect. This impedes detection and complicates training. Some forensic indicators, however, are known. For example, certain types of fractures or pressure sores almost always require further investigation, whereas others may not require investigation if adequate care was provided and documented.
- No validated screening tool. There is no standardized, validated screening or diagnostic tool for elder abuse and neglect. Such a tool could greatly assist in the detection and diagnosis of elder abuse and neglect and would serve to educate and, where appropriate, to trigger suspicion, additional inquiry, or reporting to Adult Protective Services (APS) or law enforcement. Research is needed to create and validate such a focus.
- Difficulty in distinguishing between abuse and neglect versus other conditions. Older people often suffer from multiple chronic illnesses. Distinguishing conditions caused by abuse or neglect from conditions caused by other factors can be complex. Often the signs of abuse and neglect resemble—or are masked by—those of chronic illnesses. Elder abuse and neglect are very heterogeneous; medical indicators should be viewed in the context of home, family, care providers, decision-making capacity, and institutional environments.
- Ageism and reluctance to report. Ageism results in the devaluation of the worth and capacity of older people. This insidious factor may result in a less vigorous inquiry into the death or suspicious illness of an older person as compared with someone younger. Such ageism may impede and result in inadequate detection and diagnosis, particularly where combined with physicians’ disinclination to report or become involved in the legal process.
- Few experts in forensic geriatrics. In the case of child abuse, doctors who suspect abuse or neglect have the alternative of calling a pediatric forensic expert who will see the child; do the forensic evaluation; do the documentation; and, if necessary, do the reporting and go to court. This eliminates the responsibility of primary care physicians to follow up and relieves them of the burden of becoming involved in the legal process. It increases reporting because the frontline providers feel like they have medical experts backing them up. Training geriatric forensic specialists to serve an analogous role should similarly promote detection, diagnosis, and reporting and increase the expertise in the field.
- Patterns of problems. In the institutional setting, data indicating a pattern of problems may facilitate detection. For example, the minimum data set (MDS) of information for a single facility or for a nursing home chain may include an unacceptably high rate of malnourishment that—absent an explicit formal diagnosis—should trigger additional inquiry. Similarly, a survey may cite a facility for putting its residents in “immediate jeopardy” as a result of providing poor care. Or emergency room staff may identify a pattern of problems from a particular facility. In these examples, the data itself may be a useful tool in facilitating detection of abuse and neglect. This type of information is accessible not only to health care providers but also to others (U.S. Department of Justice, 2002, p. 2).
Mandatory reporting laws and training have been used to improve the ability of professionals to identify suspected cases of elder abuse. Mandatory reporting laws are those that state that certain professionals must report suspected cases of elder abuse to the authorities (which in most cases means social services). In all, 42 states have some form of mandatory reporting law. Mandated reporters include health care professionals, social services professionals, long-term care employees, criminal justice professionals, financial employees, and other professionals who might come into contact with older persons vulnerable to victimization.
Mandatory reporting laws have both strengths and weaknesses. Supporters of the laws contend that they are necessary in order to offer protection to older persons at risk of victimization. They further contend that the laws offer a strategy to educate different groups about elder abuse. In addition, those who support these laws suggest that they send a message to the public that elder abuse will not be tolerated. Finally, supporters note that the laws offer immunity to those who report in good faith. Consequently, the laws protect reporters, thereby removing their concerns about being sued for reporting misconduct.
A number of criticisms have been levied against mandatory reporting laws. Some have pointed out that the laws were developed based on child abuse models and that there was no evidence that elder abuse dynamics were similar to child abuse dynamics. In addition, the lack of research on the need for the laws has been cited as problematic. Critics also note that the laws are ageist because they assume that at a certain point in the life course, individuals are in need of help. A lack of understanding about the laws also has been offered as a criticism. In addition, some have argued that there is no evidence that the laws work; in fact, some have suggested that mandatory reporting laws create more problems then they solve. Also, some have criticized the laws on the grounds that they are not responsive to the actual dynamics of elder abuse. On a similar point, some have noted that the laws were actually unfunded mandates because no funding came along with the passage of the laws. As well, the laws have been criticized for being politically motivated as an ineffective strategy to respond to elder abuse. Finally, some have pointed out that the lack of awareness about how to abide by the law has been problematic.
The development and implementation of different training programs has been one strategy to increase adherence to mandatory reporting laws and promote detection of elder abuse. The United States Department of Justice has provided federal funding to support the development of training curricula on elder abuse. The Office for Victims of Crime has distributed the funding so that the training could actually be carried out. The American Probation and Parole Association recently developed a training curriculum to encourage better responses to elder abuse among probation and parole officers. As well, advocates at the local level have developed training packages and programs.
Despite this increased use of training, a number of concerns have made it difficult to train criminal justice professionals about elder abuse. First, the lack of adequate state laws makes it difficult to train regarding appropriate responses. Second, a lack of specific policies and protocols creates situations where curricula are more emotionally driven, rather than empirically grounded. Third, a lack of concern about elder abuse has made it difficult to get police recruits, law enforcement officers, police executives, court officials, judges, prosecutors, probation and parole officers, and other criminal justice officials willing to participate in the training. Fourth, training is typically given a lower priority when funding decisions are made. Fifth, elder abuse training curricula are not truly based on evidence-based practices simply because no such practices have been developed to guide the criminal justice response to elder abuse. Sixth, it has sometimes been assumed that training will improve the response to elder abuse, yet no evidence has actually made this connection. Finally, curricula are often developed that are devoid of criminological theory. Failing to understand the potential causes of elder abuse results in training packages that are destined for problems.
IV. Explaining Elder Abuse
One of the most basic drives of any field of study involves efforts to explain the behavior being studied. Early elder abuse research tended to focus on the following four explanations:
- Intraindividual explanations
- Dependency explanations
- Caregiver stress explanations
- Cycle-of-violence explanations
More recently, criminologists have demonstrated how different criminological theories can be applied to elder abuse. Criminological explanations that have been applied to elder abuse include the following:
- Deterrence theory
- Strain theory
- Social control theory
- Conflict theory
- Learning theory
- Neutralization theory
- Self-control theory
- Routine activities theory
- Social disorganization theory
In this section, the way that traditional and criminological explanations have been used to explain elder abuse is considered.
Intraindividual explanations suggest that something within either the older person or the offender caused the abuse. For instance, it has been suggested that abusers tend to be unemployed individuals who have drug problems or mental health issues. Among victims, it has been found that dementia and other health-related problems place older individuals at a higher risk for abuse.
Dependency explanations suggest that the care recipient’s dependency on the caregiver places the older individual at risk for abuse. Those citing this explanation often refer to Susan Steinmetz’s (1988) concept of generational inversion to demonstrate how this dependency manifests itself. When individuals are younger, they tend to be dependent on their parents for food, resources, housing, emotional needs, and so on. As the parent ages, and the child does as well, at some point the parent may become unable to care for himself or herself. The parent then may become dependent on the child. While this explanation makes some degree of sense, experts do not all agree that dependency causes elder abuse. Some say that it may cause financial abuse, but it does not necessarily cause physical abuse.
Caregiver stress explanations suggest that abuse occurs because caregivers are unable to cope with the stress that arises from the caregiving situation. From this perspective, it is argued that adult children are not adequately prepared to become caregivers for their parents. When they become caregivers, the burden that comes along with the caregiving creates a situation where individuals may become aggressive in order to cope with the stress. While all agree that caregiving can be stressful, fewer experts agree that stress actually causes abuse. Other factors and dynamics are likely more relevant.
Cycle-of-violence explanations have suggested that elder abuse may be attributed to living in violent families. Initially, it was believed that people who abused older persons were victims of child abuse who were “getting even” with their older parents. Note, however, that no studies have supported this belief. Indeed, it is now believed that child abuse victims, because of the dynamics of their victimization experience, would rarely become the primary caregiver for their aging parents (e.g., an adult offspring will not be likely to become a caregiver for a parent that was abusive).
The above explanations were the early ones for elder abuse. As criminologists have become involved in studying elder abuse, it has become apparent that some criminological explanations can be applied to the phenomenon. For example, using deterrence theory as a guide, it is plausible that cases of elder abuse continue because individuals are able to get away with their offending with minimal, if any, punishment. Criminologist Brian Payne (2006) has argued that strain theory can be used to understand caregiver stress explanations, and self-control theory can be integrated with the intraindividual explanations. In addition, rather than looking at the cycle of violence specifically, criminologists have suggested an examination of how social learning applies to elder abuse. As well, criminologists have noted that routine activities theory easily applies to elder abuse, particularly in nursing homes. The abuser is the motivated offender, the victim is the vulnerable target, and the lack of criminal justice concern about elder abuse equates to the lack of a capable guardian. Criminologists are also now beginning to apply social disorganization theory to elder abuse. In particular, researchers are considering whether elder abuse is distributed equally across communities.
Compared with other forms of abuse, the study of elder abuse is relatively rare among criminologists. With increases in funding from the National Institute of Justice, criminologists are beginning to pay more attention to elder abuse. To better understand the phenomenon, it is imperative that criminologists work with social scientists and hard scientists from other disciplines. Doing so will help to generate increased understanding about this problem, one that is likely to increase as the proportion of older persons in society continues to grow.
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