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Elder abuse in community settings (referred to as domestic elder abuse) has been the last form of family violence to receive multidisciplinary professional interest. Depending on the source, it is thought that the numbers of abused elders in America annually range from 500,000 to 2 million. The current literature suggests that domestic elder abuse is a complex phenomenon, which may or may not involve a malicious perpetrator and may also present severe health issues, even death, to those older people who self-neglect their own needs.
Elder abuse presents as physical abuse (any action by another that produces pain or injury to the older person), sexual abuse (any intimate behavior that is undesired or lacks competent consent by the older person), and emotional abuse (inducement of fear, intimidation, or a lowering of self-esteem to punish or control the older person). It also includes the financial exploitation of an elder (using the elder’s goods, income, and assets for purposes other than the safety, benefit, and enjoyment of that elderly person). Elder abuse may be in the form of intentional or unintentional neglect at the hands of another or by elders themselves (self-neglect).
The U.S. government, although philosophically supportive of protecting older people from abuse and neglect, provides little national funding for protective services, professional training, and research opportunities (as compared with its provisions for such services regarding other forms of family violence) that would enhance the professional and public understanding of this issue. Thus, the incentive and cost for elder abuse training is usually the responsibility of those organizations and professionals who identify it as a priority and are willing to incorporate the costs into their own budgets.
There are several professional groups in need of training: (1) elder protective service professionals, often referred to as Adult Protective Services (APS) workers, who act as the responsible agents to accept reports of elder abuse and provide immediate assessment and intervention, (2) professionals who interface with the elderly as their client population (e.g., health care professionals such as physicians, nurses, therapists, and nutritionists; social workers and counselors; first responders such as fire department and police personnel and emergency medical teams; paraprofessionals such as nurses aides), and (3) community service providers (e.g., volunteers who visit the homebound; meals-on-wheels drivers servicing abused or neglected elders). The intensity and scope of training varies with the professional duties, ethics, and sanctioned responsibilities to citizen safety.
This research paper will identify training themes necessary for a wide variety of professionals who interface with the aged population; it does not address the needs of paraprofessionals or volunteers.
Professional Knowledge of Reporting Responsibility
Clearly there are certain professionals who by nature of their work carry a professional obligation to know the law and file abuse and neglect reports. Typically this includes health care providers, social workers, counselors, and first responders. Some states are considering or have already introduced legislation that would require banking or financial agents (investment firms) to also be identified reporters of financial exploitation. Consequently, professionals must know the requirements of the state law where they practice or the laws of other states in which their clients may reside.
Elder abuse laws exist in every state and in the District of Columbia. Yet, these laws are not consistent in naming expected reporters, whether reports are mandatory and carry a legal consequence if not made, where and to whom to file reports, whether only ‘‘vulnerable’’ elders are protected, and the authority of APS agency to intervene. All state laws, however, are in agreement that the professional does not need to confirm if abuse or neglect is occurring, but only needs to suspect that it may be occurring. The designated agency receiving the report, typically APS, has the responsibility of substantiating the allegation while preserving the confidentiality of the reporter should he or she request anonymity. Additionally, all laws ‘‘protect’’ the reporter from being sued by the alleged victim or family as long as the report was made without malice.
Professionals have an ethical obligation to know what their legal responsibility is to their clients; therefore, they cannot use the excuse of ignorance of their state law for not filing a report. Several organizations have websites that are easy to access and can advise professionals as to the appropriate course of action. Particularly helpful and accurate websites are those of the National Center on Elder Abuse (NCEA) and the American Bar Association Commission on Law and Aging (ABANET). However, every state’s Attorney General’s Office would be able to provide professionals with the requirements of the law. Training specific to state law may also be received from the APS agency of that state. Additionally, many police departments would have protocols to accept reports of suspected abuse and refer them to the appropriate agency.
Requiring or encouraging professionals to report elder abuse and neglect does not provide the needed assessment skills to know who should be reported. Thus professionals must understand who may be perpetrators of abusive and neglectful actions and what the key factors are in assessing for possible abuse when interfacing with elders and their family members.
Professionals need to assess the older person’s family relationships. This is because most elder abuse and neglect occurs at the hands of relatives— those very people assumed to have an interest in loving and caring for the older person. Professionals may not realize that it is the relative’s needs that may motivate his or her involvement with the elder person. Therefore, exploring the reasons behind the family involvement and the older person’s perception of that relationship is important information. For example, many older people are abused because their relatives are in need of the resources of the older person; the abuse is a tool used for controlling the older person’s resources. For example, a homeless relative may seek shelter from an older, frail aunt; or an alcoholic adult son might steal his father’s money because he cannot maintain a job. In both cases the perpetrator may threaten to hurt, or actually physically abuse, the older person to keep control of the elder’s home or money. Therefore, when a health professional assesses that an older person does not live alone, assumptions should not be made that the arrangement is for the care of the elder. Follow-up questions are often needed, such as: ‘‘Was it your idea that your granddaughter and her children move in with you? How much work has this created for you? Are you still able to use the rooms in your home or have you been restricted to one room?’’ Such questions will help the professional ascertain if the relationship is mutual and helpful or if it is coercive and possibly abusive.
Relatives who accompany older people to doctor appointments or emergency rooms and insist on being present throughout the examination may certainly be acting out of concern. But professionals need to be aware that relatives perpetrating abuse or neglect may request to remain with the elder because they fear that the older person will ask for help or share information that may expose the abuse or neglect. Therefore, professionals should insist on some time alone with older persons in order to ask questions about their well-being. Sometimes an older person is able to articulate some concerns by answering simple questions the professional might ask, such as: ‘‘Are you ever afraid that your daughter would purposefully hurt you?’’ or ‘‘I noticed that your daughter was upset when I asked her to leave us alone during this exam. Do you know why that would upset her?’’ Second marriages or late first marriages should be assessed for financial exploitation or for issues of domestic violence, including rape. Professionals should take an interest in asking about the adjustment to a new partner and if anything is making him or her feel uncomfortable or unsafe. Oftentimes older people are embarrassed by what they consider to have been poor choices, and consequently do not volunteer information unless the professional makes the time to show concern and is unhurried in listening to their responses.
Consistent with understanding the social network of the older person is also assessing for isolation. Isolation is a key factor in abuse and neglect and may present in either of two forms: the isolation that happens as one becomes frailer and physically or mentally less competent (e.g., losing the privilege of driving a car) or the isolation imposed on one person by another. The former may indicate a self-neglect scenario or the possible vulnerability to victimization. The latter may indicate a currently abusive or neglectful situation with isolation as a means of the perpetrator to control the victim.
Physical assessment of abuse should include the appropriateness of clothing with regard to the weather, as clothing may be used to cover cuts, burns, or bite marks. Examining the scalp not only for cleanliness but also for bruising due to hair pulling is necessary. Asking older people if they are able to fill their prescriptions, have groceries delivered, food prepared, and heat or air conditioning available helps in assessing environmental responsiveness to their needs. Health care providers, mental health professionals, and institutions of health care (e.g., hospitals, adult day-care facilities) should have standard assessment tools to screen for possible abuse and neglect.
Interfacing with Victims of Abuse and Neglect
For many professionals, understanding their reporting duties and becoming competent in assessing for possible abuse and neglect will be sufficient. But for professionals employed by APS agencies, intensive training is needed so that workers can provide clients with protection while preserving their autonomy (self-determination). APS professionals use many community services, such as meals-on-wheels and homemakers, for abused and neglected clients. However, such services were designed for frail elders in need of health supports, and not as supports for abuse and neglect monitoring. Agencies providing services to victims of elder abuse may not know how to provide services in an atmosphere where the perpetrator still visits or resides with the victim. Therefore, part of the training for APS professionals is learning the limitations of home services and how to develop more substantial services to meet client needs.
Several core competencies are necessary in elder abuse intervention work: understanding self-determination, completing mental competency and level-of-risk assessments, understanding the normal aging process, and knowing about ethnic and cultural norms of the victim and the victim’s family.
Professionals need to fully understand self-determination in the context of vulnerable people whose decisional abilities may be compromised because abuse and neglect produce fear and hopelessness in their victims. The ability to access competent professionals to conduct mental competency assessments while simultaneously assessing for sensory changes or mental health issues is necessary. For example, a good competency exam should be done over several interviews, in various settings, and at different times of the day in order to be accurate. Some elder abuse experts believe that evaluating the victim’s level of risk is more appropriate than competency evaluations for determining the ability of abused victims to make competent choices regarding their abusive situations.
Additionally, ethnic background and cultural norms influence the decisional process. For example, if an elderly woman of Asian heritage always depended on her husband to make difficult and complex decisions, then, although competent, she may neither have the practical skills, motivation, or cultural supports to make her own independent decisions.
The inability of clients to be compliant with agency objectives is often used by home-care agencies as the justification to discontinue services to very vulnerable people. For example, if the meals-on-wheels provider cannot navigate the garbage at the kitchen door and the client refuses or is unable to clean it, the service could be discontinued. Or if an abusive alcoholic adult child resides within the elder’s home and the elderly parent refuses to ask the adult child to leave the residence, the homemaker/health aide might discontinue services. Understanding violence, maladaptive behaviors, alcoholism and enabling relationships, and compulsive behaviors to hoard junk or even animals (e.g., multiple cats) are all necessary training issues for professionals servicing abused and neglected elders.
Lastly, training is necessary for professionals servicing older neglected and abused elders who still rely on or wish to maintain contact with abusive family members. Older people are often unwilling to press charges against their children or to deny them contact. Learning how to supervise visits of former and perhaps current perpetrators of elder abuse is necessary, as is assessing, treating, and meeting the needs of perpetrators to reduce or eliminate their reasons to abuse the victims. Additionally, knowledge about actions that constitute crimes and when to engage the legal system is necessary training.
Elder abuse requires an array of core competencies: understanding the laws in respective states, assessing for abuse and neglect, learning how to interview elders who have sensory impairments, and understanding how ethical principles of self-determination, client abandonment, and providing protection work together. Professional competency in understanding the older person’s cultural, ethnic, and family system is critical for presenting solutions and negotiating the client’s decisions with level of risk. Training may come from a variety of sources, including accessing the literature on elder abuse and neglect. But as demonstrated in this brief research paper, elder abuse and neglect is complex and requires training that is multidisciplinary and interactive, allowing professionals to present difficult cases and explore possible solutions. Professionals interfacing with older people must insist that their agencies of employment, professional associations, community organizations, government funding, and local universities and colleges provide and include ongoing training in assessment and intervention skills for working with clients vulnerable to elder abuse and neglect.
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