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Elder abuse crisis intervention techniques and their effectiveness

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Elder abuse crisis intervention techniques and their effectiveness

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ELDER ABUSE CRISIS INTERVENTION
TECHNIQUES AND THEIR EFFECTIVENESS
by
Akanksha N. Keswani
A Thesis Presented to the
FACULTY OF THE SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(Gerontology)
December 1997
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UMI Number: 1389986
Copyright 199 8 by
Keswani, Akanksha N.
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UNIVERSITY OF SOUTHERN CALIFORNIA
LEONARD DAVIS SCHOOL OF GERONTOLOGY
University Park
Los Angeles, CA 90089
This thesis, written by
Akanksha N. Keswani
under the director of h er Thesis Committee and approved by all its
members, has been presented to and accepted by the Dean of the Leonard
Davis School of Gerontology in partial fulfillment of the requirements for the
degree O f* Master of Science in Gerontology
Dean
Date ' W m n r J t t If. 7___
THESIS COMMITTEE
Chairman
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ACKNOWLEDGEMENTS
This thesis would not have been possible without the support
of my family and the professors at the Leonard Davis School
of Gerontology at the University of Southern California.
My thesis chairperson, Dr. Kathleen Wilber deserves special
mention for her guidance, expertise and knowledge. I would
like to thank Dr. Gerald Larue for serving on my thesis
committee and offering invaluable information and
professional advice. Dr. Pauline Abbot greatly motivated and
encouraged me to get this thesis completed.
I would like to thank the Field Operations Director of Adult
Protective Services, Los Angeles County, Norma Nordstorm,
for enabling me to collect the data required for this thesis
at Los Angeles County Adult Protective Services and making
sure that I had full support from APS supervisors and staff.
Also, special thanks to my respected supervisor at South ATS
and friend, Sandra Weninger, who made it easy for me to
complement my graduate studies and my work.
I thank my family for believing in me. I especially want to
thank my husband, Leslie Santiago, for his unending love and
patience during the making of this thesis. He supported me,
fought my frustrations by my side and lent me the knowledge
ii
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of his computing skills during the production of this
thesis. A very special thanks to both sets of parents, Bala
and Narain Keswani, and Thelma and Dr. S. Santiago for their
wisdom, kindness, encouragement, financial support and
unconditional love throughout the years. I also want to
thank a dear friend, Bindu Madhavan, for his help and
guidance during the Masters program.
As a practicing gerontologist and social worker for the
Adult Protective Service, Los Angeles County, I am
constantly challenged and rewarded by helping others in the
field of elder abuse prevention and crisis intervention. I
once again thank the Leonard Davis School of Gerontology,
University of Southern California for the gerontology
program which has allowed me to realize my vocation in life.
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iii
TABLE OF CONTENTS
ACKNOWLEDGEMENTS....................................... ii
LIST OF TABLES AND FIGURES............................. vi
ABSTRACT................................................viii
CHAPTER 1: THE ELDER ABUSE PROBLEM................. 01
Elder Abuse - An Overview......................... 01
Purpose of the Study............................... 05
Research Questions................................. 06
Importance and Rationale of the Study.............. 06
Assumptions......................................... 07
Limitations......................................... 08
CHAPTER 2: REVIEW OF LITERATURE..................... 09
Introduction....................................... 09
Types of Elder Abuse............................... 10
Neglect and Self-Neglect..................... 11
Psychological Abuse.......................... 16
Financial Abuse............................... 18
Sexual and Physical Abuse.................... 20
Violation of Rights.......................... 21
High-Risk Situations......................... 22
Causes of Elder Abuse.............................. 23
Physical Dependency.......................... 24
Mental Impairment............................ 26
Web of Dependencies.......................... 27
The Stressed Caregiver....................... 29
Learned Violence.............................. 31
Societal Attitudes........................... 31
Protective Services................................ 32
Philosophy.................................... 33
Unique Aspects of the APS worker............. 34
Intervention Techniques........................... 35
Short Term Intervention...................... 40
Crisis Intervention.......................... 41
Long Term Intervention....................... 45
Legal Intervention........................... 47
Summary of Literature Review...................... 51
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CHAPTER 3: METHODOLOGY............................... 53
Research Approach................................... 53
Sample.............................................. 54
Data Collection and Recording....................... 54
Origin of the Data............................. 54
Method of Collection........................... 56
Method of Recording............................ 57
Data Analysis and Processing........................ 61
Methodological Assumptions..................... 62
Methodological Limitations..................... 63
CHAPTER 4 : DATA ANALYSIS AND RESULTS................. 66
Description of the Sample........................... 66
Results of the Data Analysis........................ 66
Summary............................................. 74
CHAPTER 5: DISCUSSION................................ 93
Discussion of the Research Questions................ 93
Summary............................................ Ill
Conclusion and Recommendations..................... 112
BIBLIOGRAPHY............................................ 115
APPENDICES
A. ADULT PROTECTIVE SERVICES CODE SHEET................ 124
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v
LIST OF TABLES AND FIGURES
TABLE
1. Referrer Codes.................................... 58
2. Types of Abuse Codes.............................. 59
3. Suspected Abuser Codes............................ 59
4. APS Intervention Techniques and Resources........ 60
5. Outcome Codes..................................... 61
6. Frequency of Intervention Techniques Used for the
Various Types of Abuse............................ 64
7. Frequency of Outcome Codes for the Various Types
of Abuse.......................................... 65
FIGURE
1. Intervention Techniques Used for Financial Abuse.. 76
2. Intervention Techniques Used for Self-Neglect
Cases............................................. 77
3. Intervention Techniques Used for Physical Abuse
Cases............................................. 78
4. Intervention Techniques Used for Neglect Cases.... 79
5. Outcome of Financial Abuse Cases.................. 80
6. Outcome of Self-Neglect Cases..................... 81
7. Outcome of Physical-Abuse Cases................... 82
8. Outcome of Neglect Cases.......................... 83
9. Outcome of Elder Abuse Cases for the three months
May/June/July 1996................................ 84
10. Elder Abuse Gender Analysis...................... 85
11. Suspected Abuser Profile for Financial Abuse... 86
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12. Suspected Abuser Profile for Neglect and
Physical Abuse.................................... 87
13. Types of Elder Abuse reported during the three
months May/June/July 1996......................... 88
14. Intervention Codes for the
Successful/Unsuccessful Resolution of
Financial Abuse Cases............................. 89
15. Intervention Codes for the
Successful/Unsuccessful Resolution of
Self-Neglect Cases................................ 90
16. Intervention Codes for the
Successful/Unsuccessful Resolution of
Neglect Cases..................................... 91
17. Intervention Codes for the
Successful/Unsuccessful Resolution of
Physical Abuse Cases.............................. 92
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vii
ABSTRACT
The problem of elder abuse and elder self-neglect, though
hardly new, is becoming a problem of national proportions.
The causes of elder abuse and elder self-neglect have been
identified to be dependency due to mental or physical
impairment, web of dependencies, caregiver stress, social
isolation, sexism and greed. The public agency, Adult
Protective Services (APS) is mandated by state law to accept
and investigate reports of elder abuse and neglect using
various crisis intervention techniques.
The purpose of this study is to analyze the intervention
techniques used by crisis intervention organizations for the
problem of elder abuse and elder self-neglect. The
intervention techniques currently used by professionals are
identified to be short-term, long-term and legal
intervention techniques. Specific intervention techniques
and their effectiveness are studied through data collected
at an Adult Protective Services unit of Los Angeles County.
The study examines the effectiveness of intervention
techniques by identifying the trends of use of these
techniques. It also studies the outcome of these
intervention techniques based on the nature of the abuse.
viii
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The sample was composed of 315 unrelated cases of elder
abuse which were reported to an Adult Protective Services
Unit of the County of Los Angeles over a three month period.
Financial Abuse and Physical Abuse situations seem to have
more unresolved case percentages as opposed to the other
forms of abuse. Self-Neglect and Neglect cases are well
handled by the protective service agencies.
This study gives a practical view of the effectiveness of
our current policies and protective service agencies.
This study and other similar studies should provide the
ammunition to bring about a change in policy so that
protective services such as APS work from a position of
strength.
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ix
CHAPTER 1
THE ELDER ABUSE PROBLEM
Elder Abuse - An overview
Viewing elders as being old or aged is one of the many ways
in which elders are perceived. Elders are also viewed as
those who have entered the last phase of human development.
They are divided into the young old (those 65 to 75) and the
old old (those over 78). The term elder is accorded
overtones of wisdom and status in addition to the usual
relation to advanced age. Some recognize elders as
beneficial contributors to society while others regard them
as a drain on national resources.
Elder abuse, like other forms of abuse, is dependent on the
vulnerability of the victim. Frail, lonely and trusting
elders are the highest risk victims of elder abuse. This
troubling national problem currently appears to be below
child abuse in the frequency of abuse cases. However, this
situation is expected to worsen in the years to come as the
population ages. Another aspect of the problem is that the
true number of elder abuse cases is unknown. Present studies
suggest that about 4% of elders in the U.S., which amounts
to a population of about 1 million, are abused every year.
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However, only one out of six cases are reported (Quinn and
Tomita, 1986).
The U.S. Select Committee on Aging (1981) concluded that the
abuse of older people is far less likely to be reported than
the abuse of children and that victims of elder abuse make
up at least 4% of the elderly population. This figure
translates to a population of 1 million older Americans in
1981, who were being abused in some form or the other. In
contrast, the committee estimated that one-third of every
child abuse case was reported. In 1985, the committee
reported that the elder abuse problem was increasing
nationally and that there was an increase of 100,000
moderate to severe abuse cases annually from 1981. The
committee also reported that 82% of all adult abuse cases
reported involved elderly victims (Pepper, 1985). As of
spring 1985, 37 states had passed mandatory reporting laws
requiring that elder abuse and neglect be reported to the
authorities (Thobaben and Anderson, 1985). These state laws
vary widely in their definitions of abuse and neglect. They
also differ in the requirements of the person reporting the
abuse, the person to whom the abuse is reported, and the
penalties for not reporting abuse cases. Despite these
caveats, it is safe to arrive at the conclusion that more
elder abuse and neglect cases will be uncovered.
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Elder abuse refers to the maltreatment of persons aged 65
and older. The abuse assumes many forms including neglect,
self-neglect, verbal harassment, physical attacks,
psychological abuse, financial exploitation and violation of
civil and human rights. Studies on elder abuse and neglect
are in their embryonic stages.
Elder abuse is such a serious condition that no report
however trivial can be discounted. Yet, making an accurate
assessment of the elder's situation can take considerable
time yield limited results. The practitioners who make these
assessments must assess not only the comprehensive needs of
the elder but also of the family, because elder abuse is a
family problem. Wolf and Pillemer (1984) observe that
assessing elder abuse and neglect is rarely simple. Cases do
not fit into neat categories - instead each has its own
individual peculiarities. Often there are two victims and no
one at fault. Rather, the abused and the family are in need
of help, irrespective of the label attached to the
situation.
In case of bonafide emergencies, a variety of tasks must be
compressed into a relatively brief time (Collins and La
France, 1982). Wolf and Pillemer (1984) suggest that
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preplanned protocols for dealing with emergency situations,
as well as ready access to medical, legal and law
enforcement personnel and facilities can facilitate the
swift resolution of such cases. It is generally recognized
that the enactment of elder abuse legislation has led to
greater public recognition of the problem as well as a
growing influx of new cases (Quinn and Tomita, 1986; Wolf
and Pillemer, 1984) . The creation of a mandatory reporting
system of known or suspected cases and the creation of
public agencies such as the Adult Protective Services in
most states with abuse legislation has created a mechanism
for identifying and investigating cases of elder abuse.
In 1975, Title XX of the Social Security Act mandated and
funded protective services for all adults 18 years old or
older with no regard to income. With this federal mandate
most states created adult protective services (APS) units in
their social service agencies, while other states contracted
with public and private agencies to provide protective
services with Title XX funds. APS units have become better
known since the passing of mandatory reporting laws by 37
states. They have become synonymous with the reporting and
investigation of elder abuse and neglect.
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Purpose of the study
The purpose of the study is to study the intervention
techniques used after a problem or crisis has been reported
and the effectiveness of these techniques to resolve elder
abuse cases by collecting data at Adult Protective Services
(APS) .
A number of actions have been taken at a federal and state
level to report and investigate elder abuse. This study
explores whether these actions have resulted in the
alleviation of the problem of elder abuse in the lives of
the people involved.
The study:
1. Categorizes the cases reported to APS during a three
month period of time.
2. Identifies the intervention techniques used in
resolving the reported elder abuse case.
3. Identifies the outcome of the intervention technique
used.
4. Identifies the successfully and unsuccessfully
resolved cases and answers some questions about the
efficacy of crisis intervention.
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Research Questions
The following questions will be addressed by this study:
1. Which types of abuse are most commonly reported to APS in
Los Angeles County?
2. What are the crisis intervention resources used by the
APS worker to alleviate the problem at hand?
3. Which intervention resource is used most to alleviate or
resolve a certain kind of elder abuse?
4. What are the outcomes of these intervention techniques
and resources? What percentage of the cases in each
category were successfully resolved during the three
month period? How many cases could not be resolved?
5. What is the sexual demographic makeup of the cases ? Are
they mostly female as most other studies show?
6. What is the abuser or suspected abuser profile for each
type of abuse?
Importance and Rationale of the Study
A number of studies have been conducted on the reporting and
categorization of elder abuse. These studies have helped
propel the formation of public agencies to investigate
reports of elder abuse.
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However, very few studies have been conducted to study the
intervention techniques and their effectiveness when they
are actually used in a real life elder abuse situations.
This study is important because it determines the
effectiveness of elder abuse intervention techniques and
hence elder abuse policy by studying the outcome of the
interventions.
This study is therefore a look behind the scenes. This study
gives some indication of the effectiveness of the policy in
place and the public agencies which implement these
policies.
Assumptions
The following assumptions were made in the study:
1. The subjects studied during the three month period of
time may have been referred to APS before the study was
conducted and might have been referred to APS for the
second time during the study. The data collected in this
study were not sufficient to determine whether a subject
was referred to APS for the first time.
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Limitations
The study was limited by the following conditions:
1. This study was conducted in Los Angeles County where the
demographic makeup of its residents might make it
difficult to generalize the study to other populations.
2. The study collected data over a three month period of
time.
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8
CHAPTER 2
REVIEW OF LITERATURE
Introduction
Since the first elder abuse studies appeared in the 1970s,
the investigations and the interest of researchers, policy
makers and practitioners concerning the issue has grown
steadily- Individuals from various disciplines such as
social service (Callahan, 1982; Langley, 1981), health care
(Ferguson and Beck, 1983; Galbraith and Zdorkowski, 1984),
law (Katz, 1980; Kapp and Bigot, 1985) and adult education
( Galbraith and Zdorkowski, 1984) have publicly acknowledged
and formally accepted elder abuse as a matter of social
concern.
A critical review of literature concerning elder abuse
reveals that a common definitional frame of reference is
absent. Most elder abuse studies have included categories of
physical abuse, psychological abuse, neglect, fiduciary
abuse and violation of rights to explain elder abuse
behavioral manifestations.
Douglass and Hickey(1983, page 124) believed that "the
actions or inactions of the caregivers formed the basis of
the definitions" and the consequences of abuse and neglect
9
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were "equally damaging to the victim". They viewed their
definitional distinctions as means of deciding how support
services could have aided in the prevention of abuse and
neglect. In the use of the terms "neglect" (acts of
omission) and "abuse" (acts of commission), the definitional
dilemma will be perpetuated. Neglect is an act of omission
where the suspected abuser is abusing the elder by not
actively assisting or helping the elder. In some studies,
abuse and neglect are used synonymously.
Research conducted by Phillips (1983) suggests that even
when individuals have relatively concrete guidelines upon
which to base their perceptions, situational factors may
alter perceptions of whether a situation is one of abuse. A
number of nurses participating in a study were reluctant to
label a case as one of abuse if they found the elder to have
"some less than desirable characteristic" or if the
caregiver was elderly, infirm and perceived as "doing the
best she can".
Types of Elder Abuse
The term elder abuse can encompass a broad array of signs,
symptoms and behaviors. The literature abounds with
discussion of the difficulty regarding the nomenclature
surrounding abuse, neglect, self-neglect and mistreatment.
1 0
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Currently, it seems that the definitions of elder abuse
utilized in the clinical setting derive from the legislation
that controls the mandated reporter laws in each state. This
is so because of the absence of federal legislation, each
state relies on its own definition of elder abuse. Clinical
assessment evolves from the framework inherent in the state
laws. For example, some states such as California and Ohio,
include self-neglect in the appropriate state law, while
states like Massachusetts exclude self-neglect.
Neglect and Self-Neglect
Neglect is defined by APS as the refusal or failure to
fulfill any part of a person's obligations or duties to an
elder. Neglect as a form of maltreatment is highly
prevalent. Neglect seems to occur most frequently within the
family caregiving situation. The victims are most likely to
be quite old and cognitively or physically impaired. Neglect
seems to be related to dependency, stress and burden in the
caregiving situation. Clinical assessment of physical
neglect is much more difficult than that of physical abuse.
It is known that in elderly individuals over the age of 65,
there is an average of 3 to 5 chronic conditions (Filinson
and Ingman, 1989) . These conditions affect the presentation
of the elderly as they come to the attention of the
clinician. They may overlap with the signs and symptoms of
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neglect. The problem is that there is no way to weigh these
factors and it is difficult to emphatically state which
changes are from aging and which are the result of neglect.
Neglect arises out of an intentional omission of an activity
that could have sustained the elder's health and well-being.
The area of elder neglect is the most difficult to assess
and may take extensive interviews by health care
professionals with the elder and the caregiver in order to
discern neglect from inadequate care that results from the
convergence of a number of bad situations. Experience
suggests that the evaluation of neglect can occur primarily
on the basis of three factors:
• The elder's illness or impairment which is known to
cause to neglect.
• Intervention by the caregiver being proportional to
the needs and the requirements of care required by
the elder.
• A combination of the above.
An appropriate example would be that of persistent hunger in
an elderly person which could also be a symptom of diabetes
mellitus. This could be diagnosed as a diseased state
leading to self-neglect. The indicators would also be
paranoid ideations of poisoning. The social factors
providing this indicator of persistent hunger could be
poverty or lack of transportation to the grocery store.
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This could be perceived as self-neglect but is actually
being caused by diabetes mellitus. Many researchers have
indicated that most cases of neglect involve self-neglect,
secondary to which is the abuse of the stressed caregiver
(Filinson and Ingman, 1989).
In other cases, neglect can take the form of being confined
to a locked room, being given regular meals (mostly fast
food) with inadequate levels of personal care. Neglect
encompasses the failure to provide essential care for
physical needs such as changing the position of a bedridden
elder to avoid the formation of bed sores on the elder's
body or changing the clothing of an incontinent elder.
Generally speaking, neglect has been viewed as being less
serious than abuse with regard to the intent of the
caregiver. Neglect is seen as an act of omission and is
often referred to as "passive neglect". Some observers have
have concluded that this may not be deliberate and that it
can be alleviated by supportive services and education.
Other clinicians have noted that neglect can be deliberate
and malicious, resulting in harm, injury or damage to the
elder. This type of neglect is an act of commission and is
often referred to as "active neglect".
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Self-neglect or self-abuse means that an individual is
failing to provide the necessities of life for himself such
as food, clothing, shelter, adequate medical care and
reasonable management of financial resources (Quinn and
Tomita, 198 6). It ranges from poor grooming and eating
habits to the disintegration of the body through ignored
medical care. The financial assets of the individual may be
wasted. With the elderly, it is usually associated with the
increasing severity of mental or physical requirements. It
can include an unclean and unhealthy living environment with
animal droppings in the house. Some elders in this category
isolate themselves from those who would care for them . They
show physical signs of self-neglect such as dirty matted
hair, layers of clothing arranged inappropriately, decayed
food in the refrigerator, clutter in the house accompanied
by a stench or bad odor. Some older people who cannot cope
live too far away for their families to be of assistance or
simply have no family.
Very often the self neglecting elderly delude themselves and
believe that they can handle situations and perform their
Instrumental Activities of Daily Living (IADL) . They are in
denial of their situation and are afraid of losing control
of their own lives by letting someone assist them inside
their own home. Their frailty also leads to insecurity of
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being alone and letting people know that they are alone by
having a care provider come in to their house to look after
them. Elders who experience memory loss may insist that they
are not experiencing memory loss. Indicators could be
creditors or service providers who have not been paid but
the elder insists that he/she has been writing his/her bills
regularly.
Self-Neglect is a serious form of abuse as it is very
difficult for the protective services practitioner to
resolve or alleviate such a case. No family member or
outside agency can do anything about it, especially if the
elder is mentally competent and indulges in self-neglect due
to a compromising situation or chronic disease. The
practitioner follows the principle — When interests
compete, freedom is more important than safety (U.S. House
of Representatives Select Committee on Aging, 1981). The
client can refuse treatment and has the right to be left
alone as per his request even though his living conditions
are unsafe or unsanitary.
There are some questions as to whether self-neglect and
self-abuse should be included in elder abuse and neglect.
Salend et al. (1984) surveyed 16 states that had mandatory
reporting laws in 1981 and found that the highest percentage
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of reported cases in the neglect category were those
classified as self-neglect. In child-neglect, parents
benignly or malevolently withhold care and services that the
child needs for survival. The situation is somewhat
different with older adults, who are considered to be
responsible for themselves unless they are declared
incompetent by a court of law. Therefore if they choose to
neglect themselves, it may be a matter of bad lifestyle and
free will. Senlend et al. point out that self neglect to one
may be an exercise of poor judgment for another. Poor
judgment, habits or confusion are not enough to declare
someone as having diminished capacity and hence self
neglecting. Adult Protective Services (APS) does investigate
to mitigate the hazard and provide resources and services to
reduce the risk of potential danger to the elders or others.
Psychological Abuse
Psychological abuse is defined by APS as the infliction of
anguish, pain, or distress through verbal or non-verbal
acts. Psychological abuse produces the mental anguish
ranging from shame, confusion, disorientation, fear of
talking about certain subjects and at times even attempts at
suicide. Victims can be humiliated and made to feel
inadequate because of their inability to function on their
own. They can be ridiculed for physical disabilities, or
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mocked and made to feel guilty if they spill food because
they are old and preserve an image of dependency and
incompetency. Elders can be harassed, intimidated and
threatened by everything from name calling to being shouted
at until they become fearful for their safety. Some elders
are vulnerable and can be manipulated by being denied
information, being forced to depend on the will of others in
everything from making a phone call to spending money. The
name of the game is "control", through which the abuser
assumes power over the elders (Larue, 1992).
Psychological abuse is difficult to prove and the
practitioner is cautioned to proceed slowly. Wolf et al.
(1984) found that victims of psychological abuse are
functionally and cognitively intact, but they were most
likely to be emotionally ill. However, some families have
always spoken in loud voices or even yelled at each other as
a matter of course and consider it normal.
Victims may report being threatened by nursing home or board
and care placement, if they protest physical abuse or
threaten to tell someone outside the family or refuse to
hand over money. Some elderly find themselves physically
impaired and living alone with no one to help them. They may
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become dependent on attendants who are hired from agencies
which gives rise to a possible environment for abuse.
Financial Abuse
APS defines financial abuse as the illegal or improper use
of an elder's funds, property, or assets. The improper use
of conservatorship, guardianship and power of attorney is
also defined within the realm of financial abuse.
Usually it is family members, friends or neighbors who
notice the deteriorating financial condition of the elder.
Attentive bankers might become concerned with unusual
activity in an elder's account, when large sums are
withdrawn from savings accounts or when bank statements and
canceled checks are ordered to be sent to an address other
than the elder's home (Connelly, 1990).
Experience suggests that there are several indicators of
financial abuse. Some of them are listed below.
• Bank statements or canceled checks no longer come to
the elder's house and unusual activity in the
accounts show withdrawals of large sums of money.
• The care for the elder is not commensurate with his
income and estate.
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• A caregiver or recent acquaintance makes promises of
lifelong care for the elder in exchange for deeding
over all property or accounts to the caregiver.
• There is a lack of solid arrangements for financial
management and the caregiver is evasive about the
source of income. There is a general lack of
amenities and many bills are unpaid.
• An eviction or foreclosure arrives when the elder
thought that he or she owned the house.
Financial abuse is difficult to detect, probe and
investigate. It can be difficult to check the nature of bank
accounts and without concrete proof, a financial abuse
situation cannot be resolved. Practitioners may be required
to get a signed authorization document from the elder to
investigate financial abuse information. If financial abuse
is confirmed, practitioners can take steps to stop the issue
of checks at the social security office or redirect checks
to where they should be sent to in the first place. The
elder's credit cards may need to be canceled. A conservator
may be appointed by the court to handle the elder's
financial affairs if the elder is found to have diminished
mental capacity and is unable to take care of his financial
affairs. If the abuse is inflicted by a conservator then
probate investigators are called in for investigation. If
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large sums of money are involved, law enforcement and
bunco-forgery units may get involved.
Sexual and Physical Abuse
Sexual Abuse is defined by APS as non consensual sexual
contact of any kind with an elderly person. Indications of
sexual abuse in the elderly are rarely documented or
considered. The damage resulting from this form of abuse
affects the body, mind and spirit because the elder has been
reduced to the status of an object. An elderly victim of
sexual abuse may be reluctant to mention it due to the taboo
nature of the subject. Our culture considers the elderly to
be relatively sexless or asexual (Butler and Harris, 1976).
If one were to examine a random sample of clinical records
of patients who are over 75 years of age, it would not be
unusual to find that the genital or reproductive examination
has been deferred and that no history has been elicited. The
sexual abuse indicator for the older person may include
difficulty in walking or sitting as well as pain or itching
in the genital area. Due to the extreme sensitivity of
sexual abuse, it is important to solicit expert help
available for the purpose of providing the best possible
assessment and the least amount of psychological distress.
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Physical Abuse is defined by APS as the use of physical
force that may result in bodily injury, physical pain or
impairment. Physical abuse refers to intentional and
malicious acts that inflict physical injuries ranging from
bruises, burns, abrasions, fractures, internal injuries to
death. Medical physical abuse occurs both in poorly staffed
nursing homes and in family settings. Physical abuse can
include chemical restraints or sedation which is employed to
keep elders compliant, subdued and hence under one's
control.
Violation of Rights
The U.S. Select Committee on Aging of the U.S. House of
Representatives noted in their 1981 report titled Elder
Abuse: An Examination of Hidden Problems, that all Americans
have certain inalienable rights under the constitution as
well as federal and state laws. Some of the rights are
included in the right to personal liberty, the right to
adequate and appropriate medical care, the right not to have
one's property taken without the due process of law, the
right to freedom of assembly, speech and religion, the right
to freedom from forced labor, the right to privacy, the
right to safe living and environment, the right not to be
declared incompetent and committed to a mental institution
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without the due process of law, the right to vote and
exercise all rights as a citizen.
The violation of rights can range from not being permitted
to open one's personal mail to being totally divested of all
civil rights.
High-Risk Situations
There are some situations that seem to be particularly
dangerous for elders. A caregiver may have unrealistic
expectations of an elder and feel that the elder should be
punished if the elder does not do what the caregiver thinks
the elder is capable of doing. Families with a history of
violence or domestic abuse are potentially unsafe for the
frail elder.
Some caregivers are incapable of taking care of dependent
elders because of their own problems. Some are young,
immature and have dependency needs of their own. They cannot
take care of a frail elder, particularly if the elder is
demanding or needs a great deal of personal supervision. The
risk for abuse and neglect of the elder is higher if the
caregiver is mentally ill or has problems with alcohol and
drug abuse. Other high risk situations include those where
the caregiver is forced by circumstances to take care of the
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elder or where the care needs of the elder exceed or will
soon exceed the ability of the caregiver to meet those
needs. A caregiver who is ill may be under stress and will
be unable to adequately care for the elder. The caregiver
may also refuse services and further stress himself and
indirectly pose a high-risk situation for the elder.
Wolf and Pillemer (1984) suggest that when the caregiver is
dependent on the elder for financial support, a high risk
situation for the elder is created. If the elder does not
entertain a dependent caregiver's request for money, the
caregiver might abuse the elder who is in a vulnerable
situation. The middle aged adult child may never have worked
and may tend to be evasive about financial and care
arrangements for the elder.
Self-Neglect can also cause high-risk situations for the
elder. The elder may refuse help to light a stove which he
can't do safely, mismanage dollars, let homeless people live
with him in exchange for running errands, or refuse to keep
doctor's appointments.
Causes of Elder Abuse
Anetzberger, using data from a unique study of perpetrators
found that the following were causes of elder abuse:
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perpetrator pathology, perceived social isolation, victim
dependency and history of family violence (Filinson and
Ingman, 1989). Several researchers have noted that the
majority of the victims of elder abuse, neglect and self
neglect are physically or mentally impaired or both (Block
and Sinnott, 1979; Douglas et al., 1980; Lau and Kosberg,
1979; O'Malley et al. 1979; Rathbone-McCaun, 1978,1980;
Steinmetz, 1978; Steuer and Austin, 1980). Caregiver stress
or the stressed caregiver, learned violence, societal
attitudes such as ageism, sexism and greed and role
reversals in caregiving are other causes of elder abuse
(Wolf and Pillemer, 1989). Role reversals in caregiving
often occur in spousal relationships when the caregiving
spouse becomes disabled or sick and needs care from the
other spouse who was originally receiving care.
Physical Dependency
The inability of the elder to carry out tasks of daily
living such as personal grooming, eating and the
instrumental activities of daily living makes them
vulnerable and dependent on caregivers' actions and perhaps
literally, "at their mercy" (O'Malley et al. 1979; Hickey
and Douglass, 1981).
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The most common physical problems limiting the activity of
the elderly include arthritis, heart conditions,
impairments of the lower extremities and hips, and
impairments of the back and spine. Arthritis, rheumatism and
heart conditions account for 50% of all the conditions
placing limitations on the activities of the adults (U.S.
Bureau of Census, 1983).
In a 1983 study, the National Center for Health Statistics
reported that the specific types of activities the elderly
required help with were the activities of daily living such
as dressing, home management assistance and nursing or
medical care. The survey was conducted by a household
interview. It sampled 42,000 households with a total of
111,000 people. The types and amounts of assistance needed
increased with age.
Elders can come to feel that they are a burden because of
multiple losses of power that can come with old age. Some
older people react by becoming more compliant and
obsequious, which in turn may be a stimulus for even more
abuse. In some cases the elder may accept whatever treatment
is given (Seligman, 1975).
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Frequently, those entrusted with handling people's
resources such as property, bank acounts, stock portfolios
come to think of these resources as their own, especially if
an impairment has extended over a long period of time.
Mental Impairment
Another major cause of abuse, mental impairment in older
adults may take the form of depression, delirium and
dementia due to organic brain syndromes and Alzheimer's
disease.
It is estimated that 30% to 68% of the population over 65
will have a serious episode of depression which will
interfere with the Activities of Daily Living (Ban, 1978).
Frequently, depression is associated with the onset or
worsening of a chronic illness.
Delirium is often confused with dementia because of similar
mental symptoms such as disorientation, memory deficits,
hallucinations and a confused state of mind. It can be
caused by malnutrition, transient ischemic attacks, head
trauma and cerebro-vascular accidents and may be reversed by
medical treatment.
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Dementia, unfortunately, does not carry the same prognosis.
There are several types of dementia and they are a major
source of permanent, continually deteriorating and global
disability in older people. One-third of those afflicted
with dementia are also impaired in their daily lives and
cannot even manage routine activities such as bathing,
dressing and eating (Aronson, 1984).
Alzheimer's disease, a major illness, which is associated
with the damage to cerebral blood vessels through
artherosclerosis has been called the disease of the century.
The likelihood of contracting this disease increases with
age. Heston and White (1983) report that twenty to thirty
percent of those in their mid 80s contract it and this leads
to a constantly debilitated state. Finally, one becomes
incontinent and all verbal abilities are lost. Some
Alzheimer's victims cannot even recognize themselves in the
mirror (Butler and Lewis, 1982; U.S. Dept. Of Health and
Human Services, 1984).
Web of Dependencies
All older people are not abused. The question then becomes
why some are abused and some are not. There are probably two
factors that come into play before abuse and neglect occur.
First, there must be an individual who, for some reason,
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abuses or neglects to take necessary action. Secondly there
must be a triggering event - a crisis of some sort which
precipitates the incidence of abuse (O'Malley et al., 1983).
It maybe that the elder's impairment which is either a new
condition or is worsening, creates a crisis leading to abuse
and neglect. The abuse may occur when the need for
assistance with ADLs arises (Blenkner, 1965, 1969;
Steinmetz, 1980). Some parents expect their adult children
to take them in. Some adult children take their elderly
parents into their homes too quickly without considering
other viable alternatives or planning how they will go on
with their lives (Burston, 1978). The elderly parent and the
adult child may have a good relationship until the
impairment and dependency begins but the parent's dependency
changes the relationship by shifting the balance of power.
Wolf and Pillemer (1984), in their research, focused on
forty two physical abuse cases and found that 64% of the
abusers were financially dependent on their victims for
housing. They found that abusers were highy dependent people
both emotionally and financially. They termed this
phenomenon "web of dependencies". Hwalek, Sengstock and
Lawrence (1984), in their studies, also point out that
abuser dependencies are a major cause of abuse and neglect.
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The Stressed Caregiver
The family has traditionally been expected to provide care
and support for impaired elderly family members. Fewer than
5% of people over 65 live in nursing homes, so it is obvious
that the bulk of impaired older adults live in the community
or turn to friends and others for assistance (Bronson, 1984;
U.S. Bureau of Census, 1983; Senate Special Committee on
Aging, 1984). Family care should not be idealized or
romanticized. Some families care for their elders out of
their inability to take advantage of external support
mechanisms. Others are psychologically unable to place a
severely impaired elder in a nursing home even though the
entire family is severely deprived by the caregiving (Brody,
1985; Brody and Spark, 1966).
There are undeniable pressures on middle-aged children or
the sandwich generation, as they are called, to care for
their frail elders at home, indefinitely. Dementia, which is
the most common cause of mental impairment among older
people, has a long course, sometimes 7 to 10 years and the
period of total care (feeding, bathing, coping with bladder
and bowel incontinence) may extend over several years
(Aronson, 1984). The result is increasing isolation for the
caregiver who must focus more and more on meeting the
survival needs of the elder and forego time for herself. It
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was also found that frequent visits from other family
members increased the stress on caregivers (Zarit, Reever
and Bach-Peterson, 1980).
Caregivers have other stresses too. Frequently, the
caregivers have little understanding from their spouse and
their children. Family members may increase their demands
for attention in order to balance the attention the
caregiver is giving to the impaired elder, especially if
they do not like the elder (Schmidt, 1980). Sommers (1985)
estimates that 85% of caregivers are women. Many juggle
their families and jobs. It often happens that the adult
child who is doing the most work gets very little credit and
appreciation.
The elder himself can be a source of stress for the
caregiver. In one study, 63% of elder abusers reported that
the elder was a source of stress because of the high level
of physical and emotional care required (O'Malley et al.,
1979) . With demented elders, a number of behaviors can be
worrisome such as wandering, leaving the stove or water on,
disrobing in public and even eating in a primitive manner.
Taking care of all tasks coupled with the emotional stress
creates tension for the caregiver (Steinmetz, 1983) .
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External stressors include financial problems, overcrowding,
substance abuse, unemployment and long-term medical
problems. It was found in a study that 75% of the caregivers
experienced at least one form of stress constantly (Block
and Sinnott, 1979; Douglas et al., 1981 O'Malley et al.,
1979) .
Learned Violence
Learned Violence is definitely a contributor to abuse and
neglect in the family. Many observers have concluded that
domestic violence such as child abuse, child neglect and
spouse abuse is learned from home and passed from one
generation to another (Ackley, 1977; Kempe and Kempe, 1978;
Martin, 1976; Pizzey, 1974). This theory is sometimes summed
up as the circle of violence. Hotaling and Sugarman (198 6)
found that the cumulative research evidence does identify
the witnessing of parental violence during childhood as the
highest risk factor for violent adult abuse.The evidence
with regard to learned violence is overwhelming and should
be a red flag for geriatric and gerontological
practitioners.
Societal Attitudes
There are several societal attitudes that lead to elder
abuse, elder neglect and self-neglect. These attitudes,
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though not causes in themselves, pave the way for
maltreatment of the elderly. Among these are ageism, sexism,
attitudes towards the disabled and plain old-fashioned
greed.
Protective Services
"In 1975, Title XX of the Social Security Act mandated and
funded protective services for all adults 18 years old or
older with no regard to income...With this federal mandate
most states created adult protective services (APS) units in
their social service agencies, while other states contracted
with public and private agencies to provide protective
services with Title XX funds...APS units have become better
known since the passing of mandatory reporting laws by 37
states. They have become synonymous with the reporting and
investigation of elder abuse and neglect" (Quinn and Tomita,
1986, page 237) .
APS units are crisis intervention units. The APS
practitioner intervenes during an active crisis to affect a
positive change in the situation. The practitioner may make
use of other resources for long-term, short-term and legal
interventions.
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Philosophy
Quinn and Tomita (1986) report that in 1982 a conference
titled "Improving Protective Services for Older Adults" was
held at the University of Southern Maine and was attended by
social work and legal professionals. At this conference, a
theory of adult protection was formulated to clarify the
functioning of protective services. The four principles in
this theory, listed below, along with other established
guidelines serve to guide the protective services
practitioner.
"When interests compete, the practitioner is charged with
serving the adult client" (Quinn and Tomita, 1986, page
238). The practitioner is not charged with serving the
community's concern about the client's safety, the
landlord's concern about crime or morality, or the concern
of the client's family about their own health and finances.
The practitioner is an advocate for the client and should
work to maintain and uphold the client's rights. Just
because someone says "Do something about this elder", the
practitioner cannot always intervene.
"When interests compete, the adult client is in charge of
decision making until he delegates responsibility
voluntarily to another or the court grants responsibility to
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another" (Quinn and Tomita, 1986, page 238). Services may
not be imposed on those who are competent and who refuse to
accept them. Personal liberties should never be deprived
unless they are carried out in accordance with the law.
"When interests compete,, freedom is more important than
safety" (Quinn and Tomita, 1986, page 239). The client has
the right to refuse treatment and to be left alone in unsafe
conditions if he is competent and so desires it. Involuntary
intervention will not be initiated unless the client is
incapable of caring for himself.
"In the ideal case, protection of adults seeks to achieve,
simultaneously and in order of importance - freedom, safety,
least disruption of life style, and least restrictive care
alternative" (Quinn and Tomita, 1986, page 239). Services
should be provided only until needed. The intervention that
is chosen will be balanced against the possible impact that
it will have on the client's self esteem, will to live and a
feeling of control over his life.
Unique aspects of the APS worker
The APS worker is very different from other protective
service agencies. She is mandated by law to receive and
investigate reports of elder abuse and neglect. She cannot
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pick and choose her cases. Due to this situation, APS
workers many a time end up with cases that other agency
practitioners do not want to work on or are unable to
handle. As a result, the APS practitioner's caseload often
comprise of the toughest cases of the most troubled people
in society.
The APS worker is under intense pressure to do her job well
as the passage of elder abuse and neglect reporting laws
have put APS practitioners in the spotlight. It is not
common for the APS practitioner to appear in court to
justify her actions on behalf of the client.
Intervention Techniques
Many disciplines are involved in the assessment and
treatment of elder abuse such as gerontology, social work,
nursing, public health, legal services and psychiatry.
Specific protocols and questions are offered to assist
professionals in identifying elder abuse and neglect. When
an elder abuse situation is reported and then identified,
some form of intervention takes place by a protective
services practitioner to alleviate the problem or crisis.
The intervention stage offers short-term intervention
strategies, long-term intervention strategies, legal
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intervention strategies and crisis intervention strategies
that can be applied to each individual case.
From the moment the referral is received, professionals
begin to gather information and develop strategies.
Sometimes, the process of gathering information can be
arduous. At other times, the difficult task is to ask the
right questions which leads to an intervention technique and
the resolution of the problem. This must be done cautiously
so that the suspicions of the abuser, if one exists, are not
alerted and the abused elder's situation is not compromised.
The aim is to receive cooperation from as many members of
the family, neighbors and friends of the client and the
client himself to reach a solution after an investigation.
There are basically three types of interventions. The first
is short-term intervention, which focuses on problem
resolution with an eye to the future. The elder or the
client is the first step of the intervention. The client and
client's needs must be adequately assessed and addressed.
Since many elder abuse and neglect victims will choose to
remain with the abuser, it is necessary to work with them as
a unit without taking sides. Environmental change, reality
orientation and education can help to prevent and eliminate
abusive accidents.
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A special short-term intervention technique is crisis
intervention. The crisis could be for example a medical or
financial one. It may be a crisis affecting the well-being
of the client. Crisis intervention aims to offer immediate
therapeutic contact to the client. Diagnosis and treatment
are done at the same time.
Long term intervention is the second form of intervention
and it includes various forms of therapy, case management
and home support services to stop elder abuse and neglect.
It may take several months to sort out the alternatives and
practices before an appropriate mix of services is in place.
Case management is a popular technique where followups are
made on an on-going basis by the case managers to keep an
eye on the situation. Long term intervention is appropriate
when the abuse is long standing and the change that is
expected to come about may happen very gradually.
Legal intervention in the third form of intervention. This
form of intervention can be short-term or long-term. The
intervention can range from the least restrictive to the
most restrictive legal options that are available to the
professional or exploited client. There are remedies that do
not require court involvement such as helping a client make
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a direct deposit into a bank account or obtaining a
representative payee or durable power of attorney. There are
other remedies that involve court involvement such as
guardianships, conservatorships or even criminal
proceedings.
Experience suggests that a biopsychosocial assessment is
very important when one meets the client. In the initial
stages a referral is made with or without the prior
knowledge of the abused elder. The correct picture is seen
by the investigating professional such as the social worker,
gerontologist, case manager or the police officer.
All these professionals keep an eye open for anything
unusual. This can range from bruises to a poor level of
personal care, especially when the client has adequate money
and a care provider. The practitioner must also look out for
situations which can be a health, safety or fire hazard.
Tact and time are important when meeting and speaking with a
client. The client's privacy and autonomy must be respected
at all times and many questions leading to an assessment of
the client's mental capability must be asked.
A functional and medical assessment of the client is of
great importance. This can lead to the service requirements
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of the elder such as meals-on-wheels and in-home support
services. No matter which intervention technique is applied,
collateral contacts are very helpful. They include the next
of kin of the abused elder, neighbors, friends and
relatives. These are the people who would be willing to
assist in making headway with the client or suspected
abuser. Collateral contacts must be made promptly and before
the caregiver attempts to collude with others. Concerned
persons who make the referrals or who possess important
information are usually reluctant to become involved if they
anticipate a court appearance or having to face the
suspected abuser at a later date. Sometimes, delving into
collateral contacts may make it clear that the case is one
of sibling rivalry or family feud, one where the collateral
contacts are not concerned about the elder but what the
elder has to offer in terms of the inheritance, shelter or
the monthly check.
The strategy or intervention is not disclosed by the
practitioner. Experience suggests that the practitioner is
not to put the client's safety at stake. Interventions are
done to resolve situations with the minimum of disruption to
the client's lifestyle. Crisis intervention can lead to the
outcome of long term intervention such as placement in a
nursing home or facility.
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Short Term Intervention
This form of intervention is nearly always used before
trying the other forms of interventions in real life
situations. In short term intervention it is essential that
the goals be limited to meeting immediate client needs and
ensure that the client is out of any imminent or existing
danger. A social support network for the client is setup by
the practitioner as a first goal. The second goal is to
motivate the client to help himself and to empower the
client so as to cope with situations by using community and
familial resources. For instance, if a client has meals-on-
wheels and in-home support services for household chores, is
ambulatory and mentally competent, the client may be capable
of living independently with assistance from a few support
services.
Hence, short term intervention involves immediate problem
solving by improving the client's functional status through
social support resources which increase the client's
independence. In short term treatment, less emphasis is
placed on related development and more on educational and
anticipatory guidance. Protective agencies usually use this
method of treatment. For example, when dealing with a
pathological caregiver the short term treatment would simply
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be the physical separation of the abuser and the elder. This
may result in the elder being placed in a nursing home.
Crisis Intervention
This is a special form of short term intervention that
deserves special mention due to its widespread use as the
first form of intervention by protective agencies. A crisis
is an upset in a steady state. This definition was developed
by Caplan in 1960 (Rapoport, 1962). There is a difference
between a problem and a crisis. With a problem, the elder
does not acquire new methods of coping and the elder's
current mechanisms are adequate. In a crisis, the client
must readapt to the situation and learn new methods of
decreasing anxiety and helplessness.
The crisis theory developed by Golan (1978) summarizes the
basic tenets which are applied to elder abuse and neglect.
• Crisis situations may occur episodically. Or be
composed of a single occurrence or a series of
successive mishaps which may build up to a
cumulative effect.
• A crisis is a disturbance in the homeostatic balance
and puts the client in a vulnerable state.
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• If a problem, as defined above, persists then
further tensions may occur. Such a period is called
a state of active crisis.
Usually a crisis situation or unstable state lasts between 1
and 6 months. Interviews are always a part of the crisis-
oriented treatment. Usually, an initial contact is made with
a few follow-up calls. A third contact is made for the
evaluation of the intervention strategy. These may be spaced
out during a period of one to three months. The situation
may arise again if the client is self-neglecting. A self-
neglecting client may revert back to the same lifestyle or
go back to the abusive caregiver. The practitioner has to go
through the same sequence of actions in the next crisis.
Usually, the reintegrating phase is when the readaptive
skills of the client are assessed. If the crisis
intervention fails, then it is usually because long-term
intervention or legal intervention is required. It may also
fail if the client has maladaptive and non-compliant
patterns of behavior.
Parad (1971) considers the practitioner to be a participant,
observer and change agent during a crisis situation. In
crisis intervention, diagnosis and treatment are done at the
same time. The practitioner has to take advantage of the
client's readiness to cooperate, reduce the anxiety level of
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the client and deal with the suspected abuser. The
practitioner has to act quickly using past experience and
the ability to appraise the client's behavior and actions.
The emphasis in crisis intervention is in cognitive
restructuring and accomplishing tasks in order to achieve a
positive resolution of a specific crisis.
Hence crisis intervention can be broken down into three
steps:
• Formulation includes establishing contact with the
client, determining whether a crisis exists and
setting up a working contract for future activity.
• Implementation includes identifying and carrying out
tasks as well as organized methods to bring about
situational and behavioral change.
• Termination involves reviewing the progress,
adaptability and planning for future activities.
In a medical or physical crisis, the professional may have
to act immediately if the client is alone and needs medical
help. If the client is unresponsive, confused or disoriented
the professional should act promptly. The client may appear
malnutritioned, incontinent, dehydrated and demonstrate a
failure to thrive.
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In the event of an emergency or an obstruction from the
caregiver, forced entry may be justified. The suspected
abuser can be questioned about the client's condition.
Untreated sores, wounds or other medical conditions may be
indicators of abuse. Having determined the client's current
status, the practitioner may mobilize various resources such
as intrafamilial and community resources to further
stabilize the situation. A hospital or clinic may have to be
called. Law enforcement officers may need to be mobilized.
Financial crisis situations can be as serious as a medical
crisis. Some elderly client's have suffered financial and
material abuse which has depleted their life savings,
pension checks, real estate property and other valuables
causing them irreparable harm. Many abused elderly have
second loans taken on their homes by their children who make
initial payments and then refrain from doing so leaving the
client's fully paid home in foreclosure and the client
homeless.
In crisis intervention, there is seldom elaborate
termination. The client is reassured that help is available
and that the support network built around the client is
enough to keep the client out of danger and in capable
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hands. By this time the client is aware of the community
resources that are available for assistance.
Long Term Intervention
While many cases will be resolved during short term
intervention other cases could take as long as two or more
years to get resolved. Agencies such as APS identify
themselves as protective services and engage in crisis or
short-term intervention lasting for a mandated period of a
maximum of 90 days, while other agencies with fewer time and
budget constraints may be able to offer long term services.
APS does not engage in long-term intervention but may pass
the abuse case to other long-term intervention resources to
resolve an elder abuse situation.
In cases of self-neglect, long standing history of abuse,
long drawn chronic or terminal illness or where counseling
is required for a long period of time, long term
intervention or treatment is definitely more helpful and APS
does not remain involved for an extended period of time.
Case management is a very popular form of treatment which is
provided by the multi-purpose senior centers. They encourage
socialization and provide transportation. They also offer
effective communication through a friendly caller and have a
nutrition program. Such services are available on an
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indefinite basis. Case managers have cases for two to three
years and sometimes even they cannot change the living
habits of self-neglecting seniors. They are an excellent
community resource that can keep an eye on the client to
determine the client's situation.
In-Home Support Services (IHSS) is a long term program
offered through the Department of Public Social Services. It
is a means tested program where the client's dependencies
are weighed against the client's ability to perform ADLs,
IADLs and the client's financial and medical status. The
IHSS practitioner recommends three care providers and the
client can choose one individual to assist them. This
enables the client to live at their home longer and enjoy
the service indefinitely. The program strengthens their
social support system and assists health care practitioners
to monitor the client's condition.
Long term counseling is another long term intervention
technique. Traditionally the elderly were not viewed as
proper candidates for long term counseling. Now, for many
reasons such as coping with stages of life, they are
receiving long term counseling (Burnside, 197 6; Butler and
Lewis, 1982). There is a greater realization now that coping
with losses, chronic illnesses, mental disorders, caregiver
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stress and depression are areas which require counseling.
Counseling may take many forms such as individual
counseling, group therapy and family counseling.
Community networking is an important phase for any
professional or agency. The elder abuse network is small or
limited and thus agencies must work together to provide
appropriate protective services to the client and the
caregiver. Special attention must be paid to finding key
contacts in various agencies to assist the client. Nonprofit
or volunteer guardianship programs, protective service
agencies and some legal entities can assist in a situation.
Referrals can be made to each of these agencies to request
help in elder abuse and neglect situations. Several
communities have developed elder abuse network teams. For
self-neglecting adults home-health, case management and
protective agencies are very helpful. For other types of
abuse, legal services, mental health services, hospital
information, assistance services and law enforcement
agencies are crucial in resolving elder abuse cases.
Legal intervention
Several self-neglecting and abusive conditions arise due to
the client's diminishing capacity. In such cases the State
is asked to intervene. When the condition deteriorates to
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the extent that a crisis is foreseen, one can use legal
tools such as a durable power of attorney for the
preservation of health and finances. In cases of physical
abuse arrests by law enforcement or a restraining order is
the type of legal intervention that is required.
Elder abuse clients need legal protection and services. The
practitioner therefore has to be well versed with the legal
resources and remedies that are available to the client.
When considering the type of legal intervention to use, the
least restrictive option should be the first choice. These
include options such as direct deposit of a social security
check into the client's bank account so that the check may
not be stolen. Other least restrictive options include joint
tenancy, representative payees, power of attorney,
protective and restraining orders. The more restrictive
options such as guardianships and conservatorships may be
established by a court of law, if deemed necessary.
Legally speaking, the continuum of legal options begins with
the client not being able to write checks but being able to
sign them if someone fills it for them. Proceeding up the
scale of options, direct deposit of the client's check is
the second least restrictive legal device. The client who
receives social security benefits, supplemental security
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income, civil service and railroad retirement checks or
veteran's administration payments may have the check
directly deposited into his account. The advantages of
direct deposit are that the check cannot be stolen,
misplaced or destroyed.
Joint tenancy is another legal option which can be used
effectively especially in financial abuse situations. This
is a legal situation where two people share equal title to
an asset, a bank account or a piece of property. In abuse
situations this is a good legal device as the joint tenant
could be someone trusted other than the suspected abuser.
If a client is unable to manage his bills due to a mental or
physical disability or a drug or alcohol problem, the client
may require a representative payee. A representative payee
is a person designated by the Social Security Agency or
other federal agency to receive the check of the client for
the purpose of paying the client's bills.
The power of attorney is often used in situations where the
elder is competent and understands that he is giving up some
control to another individual to help himself. Powers of
attorney can be limited and specific or general. In
addition, in most states, a power of attorney maybe durable
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and continue after the principal becomes incapable or
incompetent. The limited and specific power of attorney is
only for a specific act. For instance, it may be to withdraw
money from an account or sell property. A general power of
attorney gives the right to the agent to handle all
financial affairs. Durable power of attorneys take two
forms, one for health care and the other for estate
matters. A durable power of attorney means that the
principal, while competent, designates an agent to make
medical decisions and manage his property in case of future
incompetency.
Restraining orders are frequently used in physical abuse
situations. The court order legally restrains the abuser
from physically approaching the client. If the abuser
violates this order he can be arrested.
More restrictive legal intervention techniques take the form
of conservatorships or guardianships. When an abused elder
is of diminished mental capacity or has been deemed
incompetent the state may decide to appoint a guardian or a
conservator to take care of the elder's affairs. The family
may also petition the court through a private attorney to be
granted a conservatorship for the elder in question.
Depending on his capabilities, a person under guardianship
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may lose civil rights such as the right to manage property,
the right to vote, the privilege to drive, the right to
choose a residence and the right to manage personal or
financial affairs. It is important to reiterate that these
are highly restrictive protective devices. If a lesser
restrictive option can be used, the practitioner always
advises the use of that legal device.
Summary of Literature Review
This literature review presented the definitions, types and
causes of elder abuse and neglect. It also presented the
protective agencies in place specifically Adult Protective
Services (APS) and the intervention techniques used by
practitioners in the field of elder abuse.
The first part of the review focused on the types of elder
abuse. It explained the various forms of elder abuse such as
Neglect and Self-Neglect, Financial Abuse, Psychological
Abuse and Physical and Sexual Abuse. The violation of an
elders rights such as him not being allowed to open his own
mail is also treated as an abuse.
The second part of the review, touched upon the causes of
elder abuse. It reviewed research on physically dependent
and mentally impaired elders as the main candidates for
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elder abuse. It also presented other factors which are
causes for elder abuse such as a Web of Dependencies,
Learned Violence and Societal Attitudes. The Stressed
Caregiver was discussed in detail as a lot of intervention
techniques are formulated with the caregiver in mind.
In its third part, the review presented the protective
services agencies which have come to be synonymous with the
reporting and intervention of elder abuse. It presented the
philosophy of these protective service agencies such as them
being the representative of the elder and nobody else. The
unique aspects of an Adult Protective Services practitioner
was discussed.
Finally, the review presented the intervention techniques in
place to alleviate and prevent elder abuse situations. Short
Term, Long Term And Legal Interventions were discussed.
Crisis Intervention, a special form of Short Term
Intervention was also discussed.
This literature review lays the framework for the study that
is presented in the following pages.
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CHAPTER 3
METHODOLOGY
The methodology used in this study is presented below. The
research approach and sample selection are presented first.
The data collection and recording procedure are then
described. Finally, the data analysis and processing of the
data is discussed followed by the methodological assumptions
and limitations.
Research Approach
The descriptive research approach was used in this study.
Polit and Hungler (1987) define the objective of descriptive
research to describe the characteristics of persons,
situations or groups, and the frequency of certain
phenomena. Descriptive studies provide information which is
absent in literature.
This study used the descriptive research approach to
describe primarily the characteristics of the situation of
elder abuse, and the frequency of intervention techniques
used and their outcome. This study provides information on
the effectiveness of these intervention techniques which is
not available in current literature.
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Sample
The sample was composed of 315 unrelated cases of elder
abuse which were reported to an Adult Protective Services
Unit of the County of Los Angeles over a three month period
of time. The elder abuse cases were grouped by types of
abuse, the intervention technique used and the outcome of
these interventions.
Criteria
The only criteria was that the elder abuse case should have
been reported to Adult Protective Services between the
months of May, June, and July of 1996.
Data Collection and Recording
An explanation of the procedure followed by Adult Protective
Services follows which is then followed by an explanation of
the actual data collection and recording process.
Origin of the Data
Adult Protective Services has a centralized intake unit.
This unit is the one where reports are received, screened
and then faxed to the appropriate APS office, according to
the zip code. Each of the eight APS offices have their
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assigned area which is defined by the zip code. Most units
have one supervisor and eight social workers(SW). The
referrals are faxed to these offices and a social worker is
assigned to the case. Cases or referrals are also
prioritized on the severity of the problem. For instance, a
case in which a client who has no food to eat, a place to
live or spend the night or a case in which the client is
undergoing physical or sexual abuse is considered an
emergency(ER). Referrals are prioritized as emergencies
(ER's), one day, three day or five day depending on the
severity of the problem and whether or not a means or
resource has been found to diffuse the problem.
Every case that comes in cannot be handled immediately by a
social worker. Hence, situations are dealt with on the phone
and later a social worker makes a home call or a face to
face visit. Social workers are mandated by law to make at
least one face to face contact to ensure that the client is
out of immediate danger. This program is a short-term crisis
intervention program. Unlike case management in which case
managers visit clients again and again, short-term crisis
intervention requires social workers to link the client with
available resources to alleviate the crisis or resolve it.
When the case is received at the APS office the supervisor
assigns it to a social worker and logs the case in a log
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book. At an average each social worker has a case load of 20
cases at any one time. The data collected to study elder
abuse intervention techniques was done at one of these APS
offices with the help of the log book mentioned above.
Cases are assigned to social workers and records pertaining
to the case such as the time to provide intervention are
maintained in the log book. When the case is due for an
update it is submitted to the supervisor. The supervisor can
suggest better methods of resolution for the case or if
nothing more can be done for the client can approve that the
case be closed. The log is then updated with the
intervention provided, the various parties contacted, and a
narrative of the activity in the case. Information is also
given on the status of the case when it was closed, whether
it was resolved or unresolved, accepted by another agency
such as the public guardians office or multipurpose senior
center or whether the client was placed at a facility.
Method of Collection
Data collection was done over a period of three months
during May, June and July 1996. The log book was reviewed
for the cases that were assigned to this unit over this
period. The information from the log book was consolidated
to study the four most common types of abuse which are
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physical abuse, neglect by others, financial abuse and self
neglect. For each kind of abuse, the individual cases were
quantified into nine variables which were thought to reflect
the nature of the abuse and the intervention technique used
to alleviate the problem. The nine variables which describe
each case are as below:
• Type of Abuse
• Emergency ?
• Referrer
• Suspected Abuser
• Was the abuse confirmed ?
• The gender of the abused.
• The intervention provided in the form of services
and resources
• The duration of the case
• The outcome of the case.
Method of Recording
These results were tabulated using the codes used by APS. A
table consisted of nine columns of the above variables.
There were four tables, one for each kind of elder abuse.
Each row reflected the data for a unique elder abuse case.
Special codes used by APS were also used in the study to
simplify the recording process. Some of the explanations of
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the codes are as follows. For a complete list of all the
codes used by APS, please refer to Appendix A.
Table I: Referrer Codes
Referrer Code Referrer
1 Eligibility Worker
2 IHSS/CSWC/Other DPSS Staff
3 Law Enforcement
4 Senior Citizens' Program/Agency
5 Visiting Nurse/Home Health Agency
6 Regional Center/Sheltered Workshop
7 Hospital/Medical clinic
8 Mental Health/Counseling Center
9 CCL/DHS Licensing Agency
10 Ombudsman
11 Other Public Agency/Entity
12 Other Private Agency
13 Landlord/Manager
14
Neighbor/Friend
15
Relative in the home
16 Relative not in the home
17 Client
18
Other/Anonymous/Unknown
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58
Table II: Types of Abuse
Abuse Code Type of Abuse
1/23 Physical Abuse
3/37 Self Neglect:
1/27 Neglect:
1/33 Financial Abuse
Table III: Suspected Abuser Codes
Suspected Abuser Code Suspected Abuser
1
Care Custodian
2
Health Practitioner
3
Parent
4
Offspring
5
Spouse
6
Other relation
7
No relation
8
Unknown
9
Self
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Table IV: APS Intervention Techniques and Resources
Code Resource/Supportive Services
1 Out-of-Home Placement, Adjustment, Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice System/Legal Services
6 Hospital/ Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
11 Physician/ Dentist
12 Visiting Nurse/ Public Health Nurse
13 Regional Center
14 Senior Citizens' Services
15 IHSS Assistance
16 Other DPSS Program
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
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Table V: Outcome Codes
Outcome Code Outcome
1 Unable to locate client
2 Unable to gain access to client
3 Client refused services
4 Client not in danger
5 No APS needed
6 Client deceased
7 Accepted for bPS/Probate
Conservatorship
8 Accepted by another agency
9 Services Completed, Problem Resolved
10 Services Completed, Problem
Unresolved
11 Client moved out of country
12 Other
Data Analysis and Processing
The data gathered has been presented in tabular form. The
frequency of a certain intervention technique used in a
specific elder abuse situation was studied. The frequency of
the outcome or reason for closing the case code was also
presented in tabular form for each type of elder abuse.
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The data for the suspected abuser for each type of case was
also tabulated. These data were studied to see whether a
certain type of abuse was inflicted by any particular type
of abuser.
A gender analysis for each type of abuse was also done using
data collected during the study.
The frequency of each of the types of abuse that was
reported was also studied to see if certain forms of elder
abuse happened more than others.
The data were then laid out in a pie chart for each type of
abuse to visually answer some of the research questions at a
glance. These data were used to evaluate the effectiveness
of these intervention techniques by computing a percentage
of the number of cases that were satisfactorily solved. A
percentage computation of the cases that were unresolved was
also done.
Methodological Assumptions
The following assumption was made in the study:
1. An evaluation of the number of cases resolved as opposed
to the number of cases unresolved for a particular type
of abuse during the three month period would give an
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indication of the effectiveness of the intervention
techniques.
2. The study assumed that the nine variables defined to
study and compare the various types of abuse were
sufficient to answer the research questions posed. Other
variables such as race and income of client may help in
taking this study further.
Methodological Limitations
The study had the following limitations:
1. The data used in the study was collected over a three
month period of time. More data over a longer period of
time may give us more accurate results.
2. The study was limited to one Adult Protective Services
unit and did not take into consideration the racial and
ethnic demography which may or may not affect the outcome
of the results. A larger sample spread over a number of
units across the state might give us a more accurate
picture of the effectiveness of these techniques.
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63
T&WT.g vx; FREQUENCY OF IMTKRVEHTIOK TECHNIQUES PSED FOR VARIOUS TYPES OF ABUSE
CODE : FINANCIAL
| ABUSE
SELF-NEGLECT i NEGLECT PHYSICAL
ABUSE
1 Out-of-Home Placement j 3 16 ' 3 2
2 Nursing Home ; o
0 0 0
3 INFO Line I o 0
: 0
0
4 Law Enforcement ' 1 2 2 2
5 Crim inal Justice System
; 11
3 i 3 5
6 Hospital/Clinic j 9
20 ; 8 3
7 Drug/Alcohol Program : 0
2 : 0 0
8 Mental Health Services | 2 6 : 1 2
9 LPS Conservatorship
I 0
0 o 0
10 Probate Conservatorship I 5 3 | 2 0
11 Physician/Dentist ; 3 6 : 7 3
12 Visiting Nurse : 6 29 13 4
13 Regional Center | 0 0 0 0
14 Senior Citizen’s Services ; 3 19
2
1
15 IHSS Assistance ■ 9
24 : 11 0
16 Other OPSS Program ; 0 1 ; 2 0
17 Temporary Shelter
! 0
2
; 0
0
18 Food/Meal Program ; 2 5 1 0
19 Vocational Training j o 0 i 0 0
20 Veterans Services 0 0 0 0
21 ID/Document Procurement 0 0 0 0
22 Community Agency 0 2 1 0
23 Clothing ! 0 0 0 0
24 Employment Services j 0 0 0 0
25 Social Security Admin : 2 3 0 0
26 Immigration Services ! 0 0 0 0
27 Other Government Agency j 2 5 0 1
28 Neighbor or Friend j 2 10 2 1
29 Landlord/Manager : 0 6 2 0
30 Family Member 15 18 13 6
31 Community Transprtation 0 0 0 0
32 Other : 3 4 4 0
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TABLE VII: FREQUENCY OF OUTCOME CODES FOR VARIOUS TYPES OF ABUSE
Outcome Codes Financial
. Abuse
Self
i Neglect
Neglect Physical
Abuse
1 Unable to Locate : 0 i 3 0 0
2 Unable to access client i 2 2 0 0
3 Client refused services 1 6 ; 4 3 1
4 Client not in danger : 9 : is 24 3
5 No APS needed : 3 12 4 1
6 Client deceased 2 i 6 2 1
7 Accepted for Conservatorship i 3 \ o 2 0
8 Accepted by another agency : 3 12 1 0
9 Services Completed, Resolved
: 14
i 57 23 8
10 Services Completed, Unresolved
! 22
; 35 14 7
11 Client moved out of country : 0 1 1 1 0
12 Other : 0 1 1 1 0
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65
CHAPTER 4
DATA ANALYSIS AND RESULTS
The results of the study are presented in this chapter under
two sections. The first section includes a description of
the sample. The second section presents the data collected
and generated and answers the research questions for which
this study was conducted.
Description of the Sample
A total of 315 cases reported during a three month period
to APS were studied. All the cases that were reported to and
investigated by APS were included in the study. The subjects
were atleast 65 years of age.
Results of the Data Analysis
This section presents the research questions, a descriptive
analysis of these research questions and the data collected
and computed.
Research Question 1: Which types of abuse are most commonly
reported to an agency such as APS ?
During the three month period of time, 315 cases were
reported to APS. Of these reports, 21 were physical abuse
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cases, 74 were neglect cases , 73 were financial abuse cases
and 147 were self-neglect cases. See Figure XIII on page 88.
Research Question 2: What are the crisis intervention
resources used by the APS worker to alleviate the problem at
hand ?
The APS worker has thirty-two defined forms of intervention
that she can use to alleviate an elder abuse situation. The
thirty-second form of intervention is defined as "Other" and
could include any form of intervention that the other
thirty-one do not cover.
Please see Table IV on page 60 for a list of intervention
techniques and resources used by the APS worker.
These intervention resources are used by the APS worker in
accordance with the basic philosophy of protective services.
Research Question 3: Which intervention resource is used
most to alleviate or resolve a certain kind of elder abuse ?
The data were tabulated for each intervention resource and
for each type of abuse. See Figure I on page 76 for the
intervention resource most used to prevent Financial Abuse.
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The data shows that family members were most used as the
resource for financial abuse cases followed by the use of
the justice system.
Figure II on page 77 shows the bar chart which shows the
intervention technique code and the number of Self-Neglect
cases that it was used on. For self-neglect cases, visitng
and home health nurses were most used. The second most used
resource was the IHSS (In-home Support Services) program of
Los Angeles County.
Figure III on page 78 shows the frequency distribution of
the intervention techniques used for Physical Abuse cases.
The most widely used resources were Family Members, the
Criminal Justice System and Visiting/Home Health Nurses in
that order.
Figure IV on page 79 show the frequency distribution of the
kind of intervention for Neglect cases. In cases of Neglect,
once again Family Members were an important resource in
alleviating neglect. Visiting Nurses were also used as an
important resource. IHSS assistance was also used as the
next major resource followed by Mental Health Services.
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Research Question 4: What are the outcomes of these
intervention techniques and resources ? What percentage of
the cases in each category were successfully resolved during
the three month period ? How many cases could not be
resolved ?
Please refer to Figure V, Figure VI, Figure VII and Figure
VIII on pages 80, 81, 82 and 83 respectively to view the
graphical distribution of the outcome of these cases for
each type of abuse. Figure IX on page 84 shows the outcome
of all cases taken as a whole for the months of May, June
and July 96. The ideal outcome code used by APS is code 9,
which means that the services were provided, completed and
the problem was resolved and the case was closed.
Figure V shows the outcomes of the financial abuse cases
reported. Approximately 22% of the financial abuse cases
reported were closed with a code 9. About 31% of the cases
were unresolved. In 18% of the cases the case was closed
with a code 4 which indicates that the client is not in
danger. In 10% of the cases, the client refused services by
APS.
Figure VI shows the outcomes of the self-neglect cases
reported. Approximately 40% of the cases, were resolved with
a code 9. However, a larger number of cases, approximately
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24%, remained unresolved with a code 10, meaning that
services had been provided but the problem was still
unresolved. About 8% of the cases were accepted by another
agency. Only about 3% of the client's refused to receive APS
services.
Figure VII shows the outcomes of the physical abuse cases
reported. Here again, nearly 38% of the cases were resolved
with a code 9. Nearly 33% of the cases remained unresolved,
even though APS services were provided. An interesting point
to note is that a larger number of physical abuse cases were
misreported. In nearly 14% of the cases, the physical abuse
report was incorrect.
Figure VIII shows the outcomes of the neglect cases
reported. About 31% of the cases were resolved
satisfactorily and about 19% of the cases remained
unresolved. In 33% of the cases however, APS determined that
the client was not in danger. In about 3% of the cases, the
client refused APS' services.
Figures XIV, XV, XVI and XVII on pages 89, 90, 91 and 92
respectively show the intervention techniques that were used
in the cases that were successfully resolved and the cases
that were unresolved. Figure XIV on page 89 shows that of
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the successfully resolved financial abuse cases, the IHSS
assistance program was used as an intervention resource 30%
of the time, followed by Visiting Nurse/Home Health and
Physician's Assistance. Figure XV on page 90 shows that the
successful resolution of self-neglect cases was achieved by
the use of Visiting Nurse/Public Health Nurse for about 26%
of all resolved cases. Out-of-Home Placement intervention
was used about 17% of the time successfully. Hospitalization
was also used about 17% of the time to resolve a self
neglect case. Figure XVI on page 91 shows that of the 40% of
the resolved cases the elders did well after hospitalization
(23%) and assistance from home health agencies (17%) . In
Figure XVII on page 92, the successfully resolved physical
abuse cases relied on the Criminal Justice System/Legal
Intervention about 24% of the time. Other successful
intervention techniques for physical abuse were Law
Enforcement, Mental Health Services, Family Members and Out-
of-Home Placement resources.
Of the 315 cases reported, 102 were resolved satisfactorily,
which is nearly 32% of the cases. 78 cases were unresolved
even though services were provided. A total of 51 cases were
closed after the initial investigation with a code of 4
which means "Client not in danger" or report unconfirmed,
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accounting for about 17% of the cases. About 2% of the cases
were accepted for conservatorship proceedings.
Research Question 5: What is the sexual demographic makeup
of the cases ? Are they mostly female as most other studies
show ?
In all four types of abuse cases, females were abused,
neglected by another or neglected themselves nearly twice as
much as males. Of all the financial abuse cases reported
females accounted for 73% of the abuse cases. They also
accounted for 69% of the Self-Neglect cases, 77% of the
Neglect cases and 71% of the Physical Abuse cases.
Of all the cases, reported between the months of May and
June 1996, 66% of all the cases were accounted for by female
elders.
Please refer to Figure X on page 85 for a graphical
representation of the cases for male and female elders.
Research Question 6: What is the abuser or suspected abuser
profile for each type of abuse ?
Data about the suspected abuser showed that for financial
abuse, the elder's offspring was the suspected abuser in
nearly 39% of the cases. Other major abusers in the
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financial abuse data turned out to be other relations who
accounted for 23% of all financial abuse cases. Another big
category for financial abuse cases were people with no
relation to the elder. This group accounted for 19% of the
financial abuse cases. See Figure XI on page 8 6 for a
graphical representation of the suspected abuser profile for
financial abuse cases.
In the Neglect scenario, the offspring once again took the
largest chunk of the pie, accounting for nearly 29% of all
the cases. Care custodians accounted for nearly 26% of the
neglect cases and other relations accounted for about 23% of
the cases. The spouse accounted for 16% of all neglect cases
as the suspected abuser. See Figure XII on page 87 for a
graphical representation of the suspected abuser profile for
neglect cases.
In the Physical Abuse case data, 42% of the abusers were
suspected to be other relations other than the offspring,
parent or spouse. The spouse accounted for nearly 24% of all
physical abuse cases as the suspected abuser. The offspring
as the suspected abuser accounted for about 19% of all
physical abuse cases reported. The care custodian was the
suspected abuser in a small 5% of the cases. People who were
not related to the elder, accounted for about 10% of the
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cases as suspected abusers. See Figure XII on page 87 for a
graphical representation of the suspected abuser profile for
physical abuse cases.
Summary
A sample of 315 elder abuse cases collected at Adult
Protective Services (APS) during May/June/July 1996 was used
to study the effectiveness of the intervention techniques
used by protective service agencies in investigating
reported cases of elder abuse.
The study analyzed the data collected and computed the total
number of cases that were resolved after APS provided
services after confirming the presence of abuse in the
reported case. First the study found that on an overall
basis, APS was successful in resolving 32% of all the elder
abuse cases that were reported during a three month period.
About 25% of the cases were unresolved after APS provided
services in the elder abuse situation.
The data collected was also analyzed in each type abuse
situation to see if APS resolved more cases of a certain
type of elder abuse more than the others. Financial abuse
was the only type of abuse which had a larger percentage of
unresolved cases than resolved cases. APS resolved nearly
74
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40% of all self-neglect cases reported to it after providing
services to the abused elder. Self-Neglect cases were the
largest number of cases reported during the three month
period accounting for nearly half of all the cases reported.
A gender analysis was presented which analyzed the data to
show that women accounted for nearly 66% of all the abuse
cases reported.
Finally, the study also analyzed suspected abuser data to
see if there was any correlation between a certain type of
abuser and a certain type of abuser. This data was presented
for each type of abuse. In physical abuse situations the
elder was abused most of the time, nearly 42% of all cases,
by other relations who were not his spouse, parent or
offspring. In financial abuse situations the study found the
offspring as the abuse perpetrator nearly 39% of the time.
In situations of elder abuse by neglect, care custodians,
offspring and other relations accounted for about 26%, 29%
and 23% respectively of all neglect cases as the suspected
abuser.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Fi gure I: I nterventi on Techni ques Used for Fi nanci al Abuse
Intervention Techniques Used For Financial Abuse (N*73)
16
14
" " ■ " " • ’ T"------ — .............. . . . > - ;
. / i - : : - y ' r - - ¥ ■ - - , - j*, *
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II
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mmm
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1 1 1 1
1 1 1 1
6 8 10 11 12 14 15 18 25 27 28 30 32
Intervention Technique Code
1 Out-of-Home Placement Adjustment
Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice System/Legal Services
6 Hospital/Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
11 Physician/Dentist
12 Visiting Nurse/ Public Health Nurse
13 Regional Center
14 Senior Citizens' Services
15 IHSS Assistance__________________
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
32 Other___________________________
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Fi gure II: I nterventi on Techni ques Used for Self-Neglect Cases
Intervention Techniques Used for Self-Neglect Cases (N*147)
1 1 I h - M II f t M m rfri m m :\u ? , 111 m I U i i' m H « 1.1. h
s
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w m m g i m
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w m m m
s
- r v: v
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1
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1
Intervention Technique Code
1 Out-of-Home Placement Adjustment
Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice System/Legal Services
6 Hospital/Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
11 Physician/Dentist
12 Visiting Nurse/ Public Health Nurse
13 Regional Center
14 Senior Citizens' Services
15 IHSS Assistance
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
32 Other _________________
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Fi gure III: I nt ervent i on Techni ques Used for Physi cal Abuse Cases
Intervention Techniques Used for Physical Abuse Cases (N*21)
i - "X." , < ~ ' ' "A ' \ - ■ ' ' ' ~ '
- - * - ' * » / ' ♦ V./ \ ' ' ' ' ' ' ' 'V '
SSil l l W ilT lTlVi r triT IVtTi'l N j H I M11 11H ll l Ti l t m n n H I U i t i t M t'li't H i l H U I l^ j.11 * 1 H I III i^ * 4 4 H (H (Vi m ■ 11111
11111(11®
V'J> %<-
" " , "1 "rr ‘ M- ' j ' jffa’ /T
S M M T
, - - , „ ;
III!
8 11 12
Intervention Technique Code
28 30
1 Out-of-Home Placement Adjustment
Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice System/Legal Services
6 Hospital/Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
1 1 Physician/ Dentist
12 Visiting Nurse/ Public Health Nurse
13 Regional Center
14 Senior Citizens' Services
15 IHSS Assistance
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
32 Other _______
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Fi gure I V: I ntervent i on Techni ques Used for Neglect Cases
Intervention Techniques Used for Neglect Cases (N»74)
14
S H : .
i _____________' . 1
. s s v w f w
■ ? s ,
W S
iSltir’
jsX-j
r
14 15 16
Technique Code
28
1 Out-of-Home Placement Adjustment
Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice System/Legal Services
6 Hospital/Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
11 Physician/ Dentist
12 Visiting Nurse/ Public Health Nurse
13 Regional Center
14 Senior Citizens’ Services
15 IHSS Assistance__________________
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/Manager
30 Family Member
31 Community Transportation
32 Other___________________________
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure V: Outcome of Financial Abuse Cases
Outcome of Financial Abuse Cases (N=73)
2 3 4 5 6 7 8 9 10 1 1 12
Outcome Code
Outcome of Financial Abuse Cases by percentage
1 Unable to locate client 2 Unable to gain access to client
3 Client refused services 4 Client not in danger
5 No APS needed 6 Client deceased
7 Accepted for LPS/Probate Conservatorship
8 Accepted by another agency
9 Services Completed, Problem Resolved
10 Services Completed, Problem Unresolved
11 Client moved out of country
12 Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure VI: Outcome of Self-Neglect Cases
Outcome of Self-Neglect Cases (N=147)
1 2 3 4 5 6 7 8 9 10 1 1 12
Outcome Code
Outcome of Self-Neglect Cases by percentage
5
8%
6
4%
1 Unable to locate client 2 Unable to gain access to client
3 Client refused services 4 Client not in danger
5 No APS needed 6 Client deceased
7 Accepted for LPS/Probate Conservatorship
8 Accepted by another agency
9 Services Completed, Problem Resolved
10 Services Completed, Problem Unresolved
11 Client moved out of country
12 Other
11 1 2 3
1 0 1«% 1% 3 % 4
9
39%
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure VII: Outcome of Physical Abuse Cases
Outcome o f Physical Abuse Cases (N=21)
1 2 3 4 5 6 7 8 9 10 1 1 12
Outcome Code
Outcome of Physical Abuse Cases by percentage
9
38%
1 Unable to locate client 2 Unable to gain access to client
3 Client refused services 4 Client not in danger
5 No APS needed 6 Client deceased
7 Accepted for LPS/Probate Conservatorship
8 Accepted by another agency
9 Services Completed, Problem Resolved
10 Services Completed, Problem Unresolved
11 Client moved out of country
12 Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure VIII: Outcome of Neglect Cases
Outcome of Neglect Cases (N=74)
.VS
Outcome Code
Outcome of Neglect Cases by percentage
1 Unable to locate client 2 Unable to gain access to client
3 Client refused services 4 Client not in danger
5 No APS needed 6 Client deceased
7 Accepted for LPS/Probate Conservatorship
8 Accepted by another agency
9 Services Completed, Problem Resolved
10 Services Completed, Problem Unresolved
11 Client moved out of country
12 Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure IX: Outcome of Elder Abuse Cases for the three months May/June/July 1996
Outcome of Elder Abuse Cases for the three months
May/June/July 1996 (N=315)
120
, 102
100
78
60
20
Outcome of Elder Abuse Cases for the three months
May/June/July 1996
111 2 3
1«M%
32%
1 Unable to locate client 2 Unable to gain access to client
3 Client refused services 4 Client not in danger
5 No APS needed 6 Client deceased
7 Accepted for LPS/Probate Conservatorship
8 Accepted by another agency
9 Services Completed, Problem Resolved
10 Services Completed, Problem Unresolved
11 Client moved out of country
12 Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure X: Eider Abuse Gender Analysis
Financial Abuse Gender
Analysis
Self-Neglect Gender Analysis
Neglect Gender Analysis
Physical Abuse Gender
Analysis
Elder Abuse Gender Analysis for the months of May/June/July
1996
Male
34%
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure XI: Suspected Abuser Profile for Financial Abuse
Suspected Abusers for
Financial Abuse (N=73)
40
35
30
25
20
15
10
5
0
" ? ✓ ^ % SS V ss< % - v. s
A • ' ‘ V. s# . .- V ✓
~ i ! ' , ’ S s i ' <
. ' /
s i v ^ - Y '- ’s
A
\ 5 s'" '
'ixt'":""'":'
1 14
,
4
j |
S t ** • • ’ " ■ ' a ’ ’ i
l o o
l l
^ (o in s a
Suspected Abuser Codes
Suspected Abusers for Financial Abuse
by percentage
9 1 2
3% 5% Q %
Suspected Abuser for
Self-Neglect (N=147)
160
140
120
100
80
60
40
20
0
ODOOOOOO
r —f v t >
Suspected Abuser for Self-Neglect
Cases by percentage
1 2 3 4 5 6 7 8 9
1 Care Custodian 6 Other relation
2 Health Practitioner 7 No relation
3 Parent 8 Unknown
4 Offspring 9 Self
5 Spouse
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure XII: Suspected Abuser Profile for Neglect and Physical Abuse
Suspected Abusers for
Neglect (N=74)
20
S
m
O
o
15
10
21
;
17
*
, jgjw
s
|12
X«v
-
I
V ' '
A
O 0
A ^ E v
o
e -
»- n to f» o >
Suspected Abuser Codes
Suspected Abusers for Neglect by
percentage
Suspected Abusers for
Physical Abuse |N=21)
9
Suspected Abusers for Physical Abuse
by percentage
8
7
« 6
s
O 5
o
| 4
Z 3
2
1
0
5
4
3 :
*
w
• X
r
z
1
• > :
v s .i '
1
l o o
%
I , 0 , 0
» - < o 1 0 ®
Suspected Abuser Codes
1 Care Custodian
2 Health Practitioner
3 Parent
4 Offspring
5 Spouse_________
6 Other relation
7 No relation
8 Unknown
9 Self
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure XIII: Types of Elder Abuse reported during the three months May/June/July 1996
Types o f Elder Abuse reported during May/June/July 1996 at APS
(N-315)
Financial Abuse Self Neglect Neglect Physical Abuse
Type of Abuse
Types of Elder Abuse Cases reported during May/June/July 1996 at APS
by percentage.
Physical Abuse
Financial Abuse
23%
Self Neglect
47%
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure XIV: Intervention Codes for the Successful/Unsuccessful Resolution of Financial Abuse Cases
Intervention Codes for the Successful Resolution
of Financial Abuse Cases
5
7%
Intervention Codes for the Unresolved Financial
Abuse Cases
Intervention Codes
1 Out-of-Home Placement,
Adjustment, Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice System/Legal
Services
8 Hospital/Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
11 Physician/ Dentist
12 Visiting Nurse/ Public Health
Nurse
13 Regional Center
14 Senior Citizens’ Services
15IHSS Assistance
16 Other DPSS Program
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than
shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization
Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
32 Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure XV: Intervention Codes for the Successful/Unsuccessful Resolution of Self-Neglect Cases
Intervention Codes for the Successful Resolution
of Self-Neglect Cases
17 3° 1 1
2 8 2% 2% 2%
2%
Intervention Codes for the Unresolved Self-
Neglect Cases
Intervention Codes
1 Out-of-Home Placement,
Adjustment, Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice
System/Legal Services
6 Hospital/Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
1 1 Physician/ Dentist
12 Visiting Nurse/ Public Health
Nurse
13 Regional Center
14 Senior Citizens’ Services
15IHSS Assistance
16 Other DPSS Program
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/Document Procurement
22 Community Agency (other
than shelter)
23 Clothing
24 Employment Services
25 Social Security
Administration
26 Immigration and Naturalization
Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
32 Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure XVI: Intervention Codes for the Successful/Unsuccessful Resolution of Neglect Cases
Intervention Codes for the Successful Resolution
of Neglect Cases
29 30
4% 13%
Intervention Codes for the Unresolved Neglect
Cases
Intervention Codes
1 Out-of~Home Placement,
Adjustment, Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice
System/Legal Services
6 Hospital/ Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
11 Physician/ Dentist
12 Visiting Nurse/ Public Health
Nurse
13 Regional Center
14 Senior Citizens' Services
15IHSS Assistance
16 Other DPSS Program
17 Temporary Shelter
18 Food/ Meal Program
19 School/ Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than
shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization
Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
32 Other
91
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Figure XVII: Intervention Codes for the Successful/Unsuccessful Resolution of Physical Abuse Cases
Intervention Codes for the Successful Resolution
of Physical Abuse Cases
^ ' V . W . V . S v . V . S ( , V t o '
13%
Intervention Codes for the Unresolved Physical
Abuse Cases
Intervention Codes
1 Out-of-Home Placement,
Adjustment, Transfer
2 Nursing Home/ Board and Care
3 INFO Line
4 Law Enforcement
5 Criminal Justice
System/Legal Services
6 Hospital/Clinic
7 Drug/ Alcohol Program
8 Mental Health Services
9 LPS Conservatorship
10 Probate Conservatorship
11 Physician/Dentist
12 Visiting Nurse/ Public Health
Nurse
13 Regional Center
14 Senior Citizens' Services
15 IHSS Assistance
16 Other DPSS Program
17 Temporary Shelter
18 Food/ Meal Program
19 School/Vocational Training
20 Veterans Services
21 ID/ Document Procurement
22 Community Agency (other than
shelter)
23 Clothing
24 Employment Services
25 Social Security Administration
26 Immigration and Naturalization
Services
27 Other Government Agency
28 Neighbor or Friend of Client
29 Landlord/ Manager
30 Family Member
31 Community Transportation
32 Other
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
CHAPTER 5
DISCUSSION
This final chapter will present the study and a discussion
of the research questions in a more subjective form.
Discussion of the Research Questions
Research Question 1: Which types of abuse are most commonly
reported to an agency such as APS ?
The four most common types of abuse reported to APS are
self-neglect, neglect by another, physical and financial
abuse. The highest number reported were self-neglect cases
which accounted for 47% of all cases reported.
There are always underlying reasons which complete the
bigger picture of elder abuse. Abuse has been more widely
reported not only due to mandatory reporting laws but also
because of demographic changes. Families have gone where
their jobs have taken them and typically children have moved
away in pursuit of careers. The review of literature
presented the fact that every senior above 65 has one to
five disabilities which limits their functional ability.
93
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Financial stress and the inability to buy services such as
hired help has led to seniors trying to cope on their own
despite their abilities and limitations.
Self-Neglect cases are more likely to recur because the
intervention is more subjective and unstructured. The
elderly have their unique set of problems and they
constantly have to adjust to these problems. In an effort to
continue the way they always lived the elderly begin to
isolate themselves. Asking for help could mean a loss of
control. Letting someone know of their situation could mean
a loss of privacy. They would rather not be embarrassed and
cope but cannot due to physical or mental disabilities.
Also the elderly are unaware of the resources available to
them through social services and senior centers and
therefore do not use these support services to their
advantage. It takes a crisis such as an abuse situation or
hospitalization before a self-neglect or other abusive
situation is brought to the notice of crisis intervention
agencies such as APS.
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Research Question 2: What are the crisis intervention
resources used by the APS worker to alleviate the problem at
hand ?
The utilization of any technique is done based on an
assessment. A bio-psycho-social assessment is made to gauge
the elderly's ability to live independently and handle their
own affairs. The biological assessment gives insight into
the elder's medical condition, medications and how often
they consult a physician. If the elder has no medications,
has not seen a doctor then home health would be an
appropriate intervention to resolve the situation. The elder
may be bed bound or unable to take his medication and in
such cases doctor's are requested to make home visits and
home health does the followups by monitoring the
medications.
The psychological or mental assessment can be done by using
a few of the mini-mental exam questions or common sense
questions such as "How much rent do you pay?" or "What is
your phone number?". The elder may exhibit memory loss at
this point and ask the provider or offspring to supply the
answers. This indicates that they do not have the mental
ability to handle their financial affairs. The social
assessment focuses on the elder's ability to utilize
community or familial resources.
95
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Based on this bio-psycho-social assessment the APS worker
may choose to use one or more of the thirty two documented
resources and support services to alleviate or resolve the
problem. Some of the commonly used resources are Family,
IHSS Assistance, Visiting Nurse/Public Health Nurse, Law
Enforcement, and Hospital Services.
Research Question 3: Which intervention resource is used
most to alleviate or resolve a certain kind of elder abuse ?
In every type of abuse the first intervention always begins
with the family. Social workers inform the elder's family
and collateral contacts about their involvement. Many a
times the families and social workers resolve the problem
together because the elder may have difficulty in following
through with the instructions and the resources to use to
alleviate a problem.
According to the data collected on financial abuse and
intervention techniques the family is the most utilized
resource along with the physician, in-home support services
and the hospital. The physician may help assess the elder's
mental capacity or competency and need for medication. Once
stable the elder may be able to handle their own finances
but in the meanwhile the client may have written out checks
96
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and forgotten. The family is urged to cancel checks, close
the current bank account and open another joint account
requiring no cash withdrawals more than a hundred dollars be
made at any one given time. The social worker may have the
account flagged or watched and make these suggestions to the
family. A family member may contact the Social Security
Administration to be a representative payee, redirect all
the bills and pay them from another state. The In-home
Support Service provider may have access to a little money
for groceries and such and the physician may be requested to
keep the family informed of any changes in the client's
medical condition. In most cases one or more resources are
most helpful and work in conjunction to alleviate a problem.
In Self-Neglect, home health and IHSS are the most utilized
resources. Here, mainly the elder needs his support services
to be strengthened in order to increase their ability to
live independently with assistance. Home health assists with
personal care, wound care, monitoring medications such as
insulin and even physical therapy. They can also arrange the
doctor's appointments and transportation. IHSS provides
assistance with laundry, running errands and fixing a meal.
Data reflects that the above two resources have assisted in
resolving 40% of the self-neglect cases.
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In Physical Abuse the data reflects that the family is often
helpful in alleviating the problem but the justice or legal
system are mainly responsible for resolving a physical abuse
situation. Although one tries to use the least restrictive
measures in situations as serious as physical abuse, law
enforcement may need to be involved. Family members may come
to the elder's rescue by accommodating them and assisting
them with relocating or obtaining a restraining order
against the abuser from the court. The termination of
physical abuse is mostly done by removing the elder or the
suspected abuser from the situation. Family is able to
provide immediate assistance as opposed to the justice
system which is slower. In extreme cases, an emergency
protective order or temporary restraining order may be
granted by the police officer on the scene.
In cases of Neglect by another, the data shows that Family,
Home Health and IHSS were the most widely used resources.
The elder may appear to be neglected but may have suffered a
stroke and the family member may not know what to do or the
kind of care to provide. The burden can be shared by IHSS
and home health nurses especially if the children are
working.
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Research Question 4: What are the outcomes of these
intervention techniques and resources? What percentage of
the cases in each category were successfully resolved during
the three month period? How many cases could not be
resolved?
The outcome of each case depends on the intervention
technique used along with the elder's capability to comply
or follow instructions to utilize the resources.
In financial abuse cases the social worker can suggest a
durable power of attorney or a conservatorship but the
family or elder may not agree. The resource is offered but
may not be fully utilized. According to the data 31% of the
financial abuse cases were unresolved and 22% were resolved.
Ironically, the justice or legal system along with the
hospital and family were utilized in the 31% of the cases
that remained unresolved. In the successfully resolved cases
the resources most effectively used were IHSS, Physicians
and Home Health. The client may have been hospitalized,
stabilized with medication and returned home with IHSS
support thus enabling him to handle their own affairs.
Figure XIV indicates that the most effective means of
resolving financial abuse cases are the IHSS and home-health
system. IHSS is a major support resource and is an integral
part of the clients network of dependency. The elderly are
99
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
also very receptive to what their physicians suggest to
them. It is interesting to note that IHSS along with home
health is not only utilized as a support system but as a
protective system. They act like watchdogs for the elderly
and mobilize resources for the client if necessary.
Experience has shown that IHSS workers assist the client not
only with personal care issues but also provide other types
of assistance such as paying bills, running errands, monitor
the family situation and report any cases of elder abuse to
APS. Experience has shown that IHSS workers and registered
nurses have lengthy conversations with their clients during
the course of their providing support for the elder and thus
are able to identify the elder's needs in a more personal
manner.
Figure XIV also suggests that the criminal justice system,
law enforcement and the family are not helpful in resolving
financial abuse cases as might be expected. There could be a
number of reasons for this. Based on the author's
experience, the elder's for the most part are dependent on
others for driving them to the courts, banks or to an
attorney's office. The elder's do not have the patience to
deal with the long drawn and time consuming procedures of
the criminal justice system. The author has also seen during
the course of her daily work that financial abuse prevention
100
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is very much a matter of economics. The amount of money
involved such as a check for $800.00 from the social
security administration may not be large enough for the
Office of the Public Guardian (OPG) to get involved. Figure
XIV also indicates that family based intervention does not
seem to help financial abuse situations. An interesting
point to note in Figure XI is that the suspected abuser
profile for financial abuse cases was family. Nearly 46% of
all the suspected abusers were immediate family such as the
offspring and spouse. Another 23% were family members other
than the spouse and offspring. A layman might assume that
financial abuse of an elder is perpetrated mainly by third
parties but the data suggests otherwise. It is also
interesting to note that care custodians and health
practitioners constituted a minute portion of the financial
abusers profile.
To summarize the data on financial abuse, it seems clear
that IHSS and home health agencies play an important role in
alleviating financial abuse. Fifty eight percent of the
resolved cases utilized the IHSS and home health system to
successfully intervene in financial abuse situations.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In Self-Neglect cases 39% of the cases were resolved and 24%
unresolved. In the successfully resolved cases home health,
hospitals and placement in facilities were most utilized
interventions. Elders may have voluntarily agreed to
placement after brief hospitalization and the realization
that they can no longer return home without a support
system. In most self-neglect cases, if the elder is alert
and accepts services, home health may be very helpful in
keeping the elder stable and giving the elder the ability to
live independently. By the same token for the rest of the
24% home health did not work effectively. The client may
have refused treatment or may need hospice care but wanted
to be left alone. Hence the intervention techniques are as
effective as the elderly want them to be.
Figure XV shows that the intervention techniques which
resolved a large number of self neglect cases comprised of
external agencies or community based resources such as
hospitals, visiting nurses, IHSS, out-of-home placement
agencies and senior citizen's services. All of these
successful intervention methods accounted for 83% of the
successfully resolved cases. The author has used these
resources to intervene on behalf of her clients and believes
these services work well for the following reasons. IHSS and
home health services provide services which allow the client
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to perform his or her most important basic chores like
cleaning, housekeeping and cooking. Hospitals and out-of
home placement agencies such as board and care agencies
bring about stability for an elder with multiple health
problems and very low social support systems. Before placing
a client in an out-of-home facility, the client is consulted
if the client can make his or her decisions. In many cases,
the client refuses to be placed out-of-home till a crisis
situation occurs.
The data for the unresolved self neglect cases shows that
these very same support services such as hospitals and
visiting nurses and out-of-home placement agencies that
worked so well for many clients failed for many others. It
is important to note that self neglect is a difficult
situation for a practitioner to alleviate. The abuser is the
client himself and has to work with the social worker to
help himself. The client has the right to refuse any or all
the services provided by the practitioner and the
practitioner has to respect the client's decision.
Experience suggests that many self neglect cases are
recurring cases. The elder may not utilize the resources
provided to him or may fall again into a situation of self
neglect. In such cases, support services are only as good as
the use of them by the elder.
103
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In Neglect cases, the data reflects that in 33% of the cases
the allegations were unconfirmed. 31% of the cases were
resolved and only 19% remained unresolved. Figure XVI on
page 91 shows that of the 40% of the resolved cases the
elders did well after hospitalization (23%) and assistance
from home health agencies (17%). Neglect by another can
encompass a wide array of problems. The dependent offspring
may be using the elders money to support a habit or paying
their own rent and not providing the elder with food or
medication. As experience suggests clients very often are
hospitalized by overwhelmed family members who do not know
how to treat bed sores. Even though the hospital social
services report such problems to APS, doctors may confirm
that the bed sores were caused by the elders skin condition
and not by neglect. Based on the author's experience, most
neglect cases occur due to the elder's inability to perform
his Activities of Daily Living and Instrumental Activities
of Daily Living and the lack of knowledge of the resources
available to them.
In the unresolved neglect cases, it is interesting to note
that all the legal intervention used such as law enforcement
and the criminal justice system did not work at all. Law
enforcement and the criminal justice system may sometimes be
used to arrest and prosecute the suspected abuser using
104
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neglect penal codes but the data reflects that these
interventions do not work. The data also reflects that in
30% of the unresolved cases, home health services were used
to intervene but did not work. Elders may have home health
services after being released from the hospital but they
would still need a lot of assistance. An elder may need a
catheter emptied, a diaper changed or their position changed
every two to three hours if they are bed bound in order to
avoid bed sores. But sometimes elders may want to be left
alone, may fall frequently, refuse all assistance and in
such cases even though home health , physicians and social
workers are involved, the case may remain unresolved. The
elder's autonomy is respected and the situation remains
unchanged.
The outcome of Physical Abuse cases was that 38% were
successfully resolved as opposed to the 33% unresolved
cases. In the successfully resolved cases the intervention
techniques most used were law enforcement and the criminal
justice system. Most physical abuse cases require
hospitalization or monitoring by home health agencies and
these resources also helped in resolving the physical abuse
situation. Figure XVII illustrates that 37% of the
successfully resolved cases were handled by the criminal
justice system and law enforcement. It is worth noting that
105
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the criminal justice system works much better in physical
abuse resolution than for financial abuse resolution. The
main reason for this in the author's opinion is that most
physical abuse cases are reported to law enforcement by APS
workers and other practitioners. A police unit is called out
to take stock of the situation. If the police find any
evidence of physical abuse such as a bruise they may make an
arrest if the perpetrator is present at the scene. The case
enters the criminal justice system through the police
detectives report and if the case is found prosecutable, the
perpetrator is called for a hearing at the city attorney's
office before it is passed on to the District Attorney's
office and then on to the courts. Thus, in physical abuse
cases, the criminal justice system and law enforcement are
empowered to pursue avenues for prosecution. However, in
financial abuse cases, the elder and the elder's family has
to be more proactive in combating the abuse. In physical
abuse situations the intervention is more structured and
assistance and advise is sought directly from the criminal
justice system and law enforcement.
Figure XVII also shows that about 28% of the unresolved
cases were handled by the law enforcement and criminal
justice system. The suspected abuser may play an important
role in the form of intervention that is used. Many times,
106
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the elderly victim may deny the physical abuse charges
against the abuser and the criminal justice system will not
have a case. Figure XII shows that the suspected abuser
profile for physical abuse cases. Offspring and spouses
account for a whopping 43% as suspected abusers. Another 42%
is accounted for by other relations. This tells us that
nearly 86% of all suspected physical abusers are somehow
related to the victim. Experience suggests that the elder in
many cases will not press charges against a relative and in
such cases the law enforcement and criminal justice system
may walk away from the situation, unless compelling evidence
is visible.
Finally, Figure IX also illustrates an that nearly 17% of
the cases which were reported to APS were closed with a code
4 which means "Client not in danger". A small percentage of
cases, 7%, were closed with a code 5 which means "No APS
needed". The point to note is that APS is a crisis
intervention unit and non-critical cases may be reported to
APS. The APS social worker may provide the client with
information or leave a phone number with the client for use
in the future may the need arise. Such cases, are generally
closed with a code 4. Other cases may be reported which
require no APS intervention as the problem may already have
been resolved by a family member or friend.
107
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Research Question 5: What is the sexual demographic makeup
of the cases ? Are they mostly female as most other studies
show ?
The data reflects that 66% of the abused elderly were
females as opposed to the 34% males. The average lifespan of
a male is 72 years and a female is 79 years.(Torres-Gil,
1992) . As the female elders grow older and lose their loved
ones their condition begins to decline. Other individuals
and sometimes their own offspring see them as an outlet for
money or even a house to live in. Children may move in
wanting to take care of the elderly mother and very often
she may sign over the house and put them on her bank account
putting herself in a situation with a potential for abuse.
Research Question 6: What is the abuser or suspected abuser
profile for each type of abuse ?
In Neglect and Financial Abuse cases the data show that the
offspring is the suspected abuser in the highest number of
cases. The offspring has the closest proximity to the
elder's accounts and funds. They may have some physical
dependency or substance abuse may be prevalent which leads
to neglect and financial abuse. Very often the types of
abuse are interlinked and more than one may be present.
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An interesting point to note in Figure XI is that 4 6% of the
suspected abuser profile for financial abuse cases was the
immediate family such as the offspring and spouse. Another
23% were family members other than the spouse and offspring.
A layman might assume that financial abuse of an elder is
perpetrated mainly by third parties but the data suggests
otherwise. It is also interesting to note that care
custodians and health practitioners constituted a minute
portion of the financial abusers profile.
Figure XII shows that the suspected abusers for neglect are
to the most part divided between care custodians and family
members. Non-family members are encouraged to be care
custodians as this ensures a professional relationship
between the caregiver and the elder. In many cases however,
the family member may be the care custodian and this study
did not have the data required to make this distinction.
Experience suggests that neglect by care custodians is
rarely reported until a crisis situation occurs as the elder
may fear that if he complains about the care custodian and
if the care custodian is found to be the abuser, he will
have to face the consequences of moving into a nursing home
or incurring the anger of other care custodians if already
in a nursing home environment.
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Figure XII shows that the suspected abuser profile for
physical abuse cases. Offspring and spouses account for a
whopping 43% as suspected abusers. Another 42% is accounted
for by other relations. This tells us that nearly 86% of all
suspected physical abusers are somehow related to the
victim. A layman might assume that in Physical Abuse cases
those individuals who are not immediate family may have less
attachment or patience with the elder. The data suggests
otherwise. Immediate family is as likely to perpetrate
physical abuse as extended family.
In some cases children are more eager to handle financial
affairs rather than provide active support especially if
they work or live in a different state or a long distance
from the elder. It is possible that even when they do
provide support, they begin to think that the elder's money,
house and property already belong to them and begin to
mismanage it. Elder's may befriend strangers because they
may fear living alone or long for companionship and may end
up being taken advantage of by the stranger. Many of these
cases result in physical abuse and intimidation because the
elder may object to drug or other non-allowed activity in
the house.
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In any type of abuse if the elder is alert and oriented, no
matter how many resources are available, the elder has to
take the initiative to terminate the abuse.
Summary
In the author's opinion, the study showed that protective
service agencies are resolving a good number of their cases.
Approximately 32% of all reported cases were successfully
resolved by APS. This percentage might be misread to mean
that 68% of the cases received by APS are not resolved. This
is incorrect. About 25% of the cases that are reported to
APS are unresolved after APS provides the intervention it
can.
It must be understood that the remaining cases, about 36% of
the reported whole, fall into a variety of categories such
as Client Not In Danger, No APS Needed, Client Refused
Services. Small percentages, about 5%, of the cases are
accepted by other agencies for resolution of the situation.
Conclusion and Recommendations
This study used a sample of 315 cases reported over a three
month period and is large enough to be of some significance.
The information presented in this study will be most useful
to protective services managers and practitioners, policy
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makers and other gerontological associations, who can use
these data to provide training to the protective services
worker based on unresolved cases. Financial Abuse and
Physical Abuse situations seem to have a higher percentage
of unresolved cases as opposed to the other forms of abuse.
Self-Neglect has the highest percentage of resolved cases
and is well handled by the protective service agencies.
This study gives a practical view of the effectiveness of
our current policies and protective service agencies. The
study provides us some important conclusions such as IHSS
and home health services are more effective in alleviating
financial abuse than are law enforcement and the criminal
justice system. The study finds that most perpetrators of
financial abuse are family members. The study also finds
that family members both immediate and extended are
perpetrators of physical abuse. Family members also account
as the prime perpetrators of neglect though care custodians
also comprise a large number of the suspected abuser
profile. In the author's opinion, this statistic may account
for the fact that law enforcement and the criminal justice
system are not very good support system/resource to use for
intervention. If the perpetrator is a third party, it may be
easier to get the elder to press charges.
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On the other hand, home health and support services are
major contributors to the successful resolution of elder
abuse situations throughout the board.
Policy should be formulated with the above statistic in
mind. Many proposals have been presented to control the
growth of Medicaid spending. In 1995, approximately 60% of
Medicaid long-term care spending were for the elderly on
services such as nursing facilities, personal care, home-
health, home and community based services (Weiner, 1996).
Proposals to control Medicaid spending need to confront the
problem of long-term care expenditures. Over the last
fifteen years many states have expanded home and community
care to create a more balanced long-term care delivery
system (Weiner, 1996) . In 1993, approximately fifteen
percent of Medicaid spending was for long-term care
expenditures for the elderly. Most of these expenditures
were for optional care rather than mandatory home health
care (Weiner, Illston and Hanley, 1994). Some states may
choose to reduce home and community based coverage if faced
with budget constraints in Medicaid funding especially if
they are not cost-effective substitutes for nursing home
care. Policy formulators need to be given data such as the
one presented in this study so that home and community based
services are not just compared with nursing home care on a
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cost basis but also on the basis of their effectiveness of
providing care, and preventing and alleviating elder abuse
situations•
Data presented in this study also reveals that immediate and
extended family accounted for a large portion of the
suspected abuser profile in physical abuse, financial abuse
and neglect situations. Can policy be formulated to help
prevent this distressing situation? The author believes that
it may be possible depending on the cause for the abuse. If
the family member is stressed during the course of providing
care for the elderly, policy may help relieve this stress in
any way possible. Private insurance for home based long-term
care could be encouraged so that at least a portion of the
family member's caregiving responsibilities can be
transferred to a home health agency by paying for their
services. Such policy would be for the long haul so that
tomorrow's elders will have the money to pay for home based
long-term care. Currently, only about 5% of the elderly have
some kind of private long-term insurance and most of these
policies are deficient in terms of coverage care (Weiner,
Illston and Hanley, 1994) . Payments for such insurance will
need to start at a young age and people need to be educated
about the need for long-term care, specifically in-home
long-term care, in their old age.
114
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BIBLIOGRAPHY
D. Ackley. A Brief Overview of Child Abuse. Social
Casework, 58:21-24, 1977.
American Public Welfare Association of State Units on Aging
(NASUA). A Comprehensive Analysis of State Policy and
Practice Related to Elder Abuse: A Focus on Legislation,
Appropriations, Incidence Data and Special Studies.
Technical Report, APWA, 1986.
American Public Welfare Association of State Units on Aging
(NASUA). A Comprehensive Analysis of State Policy and
Practice Related to Elder Abuse: A Focus on roles and
Activities of State-Level Agencies, Interagency
Coordiantion Efforts and Public Education and Information
Campaigns. Technical Report, APWA, 1986.
American Public Welfare Association of State Units on Aging
(NASUA). A Comprehensive Analysis of State Policy and
Practice Related to Elder Abuse: A Focus on State
Reporting Systems. Technical Report, APWA, 1986.
J. A. Arlow. Psychoanalysis. In Current Psychotherapies.
F.E. Peacock, Ithaca, IL, 2 edition, 1979.
M. K. Aronson. Update of Alzheimer's: Introduction.
Generations, Quarterly Journal of the Western
Gerontological Society, 9:5-6, 1984.
T. A. Ban. The Treatment of Depressed Geriatric Patients.
American Journal of Psychotherapy, 32:93-104, 1978.
G. Baruch and R. C. Barnett. Adult Daughters' Relationships
With Their Mothers. Journal of marriage and the Family,
45:601-606, 1983
H. N. Butler and M. I. Lewis. Sex After Sixty- A guide for
men and women for their later years. Harper and Row, New
York, 1976.
R. N. Butler and M. I. Lewis. Aging and Mental Health:
Positive Psychosocial and Biomedical Approaches. C. V.
Mosby, St. Louis, 3 edition, 1982.
M. Blenkner. Social Work and the Family. In Social Structure
and the Family: Intergenerational Relationships.
Prentice-Hall, Englewood Cliffs, NJ, 1965.
115
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
M. Blenkner. The Normal Dependencies of Aging. In The
Dependencies of Old People. University of Michigan
Institute of Gerontology, Ann Arbor, 1969.
S. Brown. The Second Forty Years. Coalition for the Medical
Rights of Women. Transcription of a speech to the Fifth
Annual Conference of the California Psychiatric
Association, San Francisco, December 1978.
H. Brotman. Every Ninth American. Technical Report Comm.
Pub. No. 97-332, U.S. House of Representatives Select
Committee on Aging, 97th Congress, Government Printing
Office, Washington, D.C., 1982.
E. M. Brody. Parent Care as a Normative Family Stress. The
Gerontologist, 25:19-29, 1985.
E. M. Brody and G. Spark. Institutionalization of the Aged:
A Family Crisis. Family Process, 5:76-90, 1996.
M. R. Block and J. D. Sinnott. The Battered Elder Syndrome:
An exploratory study. University of Michigan Center on
Aging, Maryland, 1979.
I. M. Burnside. Nursing and the Aged. Mc-Graw Hill, New
York, 1976.
G. R. Burston. Do your elderly parents live in fear of being
battered ? Modern Geriatrics. November 1978.
R. R. Carkhuff and W. A. Anthony. The Skills of Helping.
Human Resource Development Press, Amherst, MA, 1979.
J. Callahan. Elder abuse programming-will it help the
elderly? Urban and Social Change Review, 15:15-16, 1982
V. G. Cicirelli. Helping Elderly Parents: Role of Adult
Children. Auburn House, Boston, 1981.
V. G. Cicirelli. Adult Children and their Parents. In Family
relationships in later life. Sage Books, Beverly Hills,
1983.
V. G. Cicirelli. Adult Children's Attachment and Helping
Behavior to Elderly Parents: A Path Model. Journal of
Marriage and Family, 45:815-825, 1983.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
M. Collins and A. B. La France. Improving Protective
Services of Older Americans: Social Worker Role.
Technical report, Human Services Development Institute,
Center for Research and Advanced Study, University of
Southern Maine, ME, September 1982.
Commission on the Status of Women. Facts About Comparable
Worth. COSW Publication, San Francisco, 1984.
M. Connelly. Elderly victim of Lincoln S&L loss takes own
life. The Los Angeles Times, November 29, 1990.
H. Davidson. Mandatory Reporting of Child Abuse: History and
Recent Developments. Paper presented to the National
Conference on Abuse of Older Persons, March and April
1981.
R. L. Douglass and T. Hickey. Domestic Neglect and Abuse of
the Elderly: Research findings and systems perspective
for service delivery planning. In Abuse and Maltreatment
of the Elderly: Causes and Interventions. John Wright,
PSG, Littleton, MA, 1983.
R. L. Douglass, T. Hickey, and C. Noel. A Study of the
Maltreatment of the Elderly and Other Vulnerable Adults.
Technical Report, Institute of Gerontology, University of
Michigan, Ann Arbor, 1980.
J. J. Dowd. Aging As Exchange: A Preface to Theory. Journal
of Gerontology, 30:585-594, 1975.
R. W. English. Combating Stigma Toward Physically Disabled
Persons. In The Psychological and Social Impact of
Physical Disability. Springer, New York, 1977.
R. W. English. Elder Abuse. Franklin Research Center,
Philadelphia, 1980.
D. Ferguson and C. Beck. H.A.L.F. - A Tool to Assess Elder
Abuse Within the Family. Geriatric Nursing, 4:301-304, 1983.
R. Filinson and S. R. Ingman. Elder Abuse: Practice and
Policy. Human Sciences Press, NY, 1989.
D. Finkelhor. Common Features of Family Abuse, In The Dark
Side of Families: Current Family Violence Research. Sage,
Beverly Hills, 1983.
E. Fromm. The Anatomy of Human Destructiveness. Holt,
Rinehart and Winston, New York, 1973.
117
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
A. L. Ganley. Court Mandated Counseling For Men Who Batter.
A 3-day Workshop for Mental Health Professionals. Center
for Women Policy Studies, 1981.
R. J. Gelles. The Violent Home. Sage, Beverly Hills, 1972.
D. G. Gil. Violence Against Children: Physical Child Abuse
in the United States. Cambridge University Press,
Cambridge, 1971.
N. Golan. Treatment in Crisis Situations. Free Press, New
York, 1978.
N. Golan. Crisis Theory. In Social Work Treatment:
Interlocking Theoretical Approaches. Free Press, New
York, 1979.
R. J. Gelles and M. A. Straus. Determinants of Violence in
the Family: Toward a Theoretical Integration. In
Contemporary Theories About the Family, 549-581. Free
Press, New York, 1979.
M. W. Galbraith and T. Zdorkowski. Teaching the
Investigation of Elder Abuse. Journal of Gerontological
Nursing, 10:21-25, 1984.
M. W. Galbraith and T. Zdorkowski. Heuristic Models of Elder
Abuse: Implications for the Practitioner. Lifelong
Learning: An Omnibus of Practice and Research, 7:16-21,
1984 .
T. Hickey and R. L. Douglass. Neglect and Abuse of Older
Family Members: Professionals' Perspectives and Case
Experience. The Geronotologist, 21:171-17 6, 1981.
M. J. Hennessey. Music and Group Work with the Aged. In
Nursing and the Aged. McGraw-Hill, New York, 197 6.
G. Hotaling and D. Sugarman. An Analysis of Risk Markers in
Husband to Wife Violence: The Current State of Knowledge.
Violence and Victims, 1:101-124, 1986.
M. Hwalek, M. C. Sengstock, and R. Lawrence. Assessing the
Probability of Abuse of the Elderly. Presented at the
Annual Meeting of the Gerontological Society of America,
November 1984.
J. J. Herr and J. H. Weakland. Counseling Elders and Their
Families. Springer, New York, 1979.
118
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
B. Justice and R. Justice. The Abusing Family. Human
Services press, 1976.
E. S. Johnson and B. J. Bursk. Relationships Between the
Elderly and Their Adult Children. The Gerontologist,
17:90-96, 1977.
M. Kapp and A. Bigot. Geriatrics and the Law. Springer, New
York, 1985.
S. Katz, L. G. Branch, H. H. Branson, J. A. Papsidero, and
J. Beck. Active Life Expectancy. The New England Journal
of Medicine, 309:1218-1223, 1983.
C. Kirkpatrick. The Family As Process And Institution.
Ronald Press, New York, 1955.
C. H. Kempe and R. S. Kempe. Child Abuse. Harvard University
Press, Cambridge, MA, 1978.
A. Langley. Abuse of the Elderly. U. S. Department of Health
and Human Services, Project SHARE, Washington, D. C.,
1981.
G. Larue. Geroethics. Golden Books, Buffalo, NY, 1992.
E. A. Lau and J. I. Kosberg. Abuse of the Elderly by
Informal Care Providers. Aging, pages 10-15, 1979.
D. Martin. Battered Wives. Pocket Books, New York, 1976.
National Center for Health Statistics. Americans Needing
Help to Function at Home. Technical Report No. 92, 1983
T. A. O'Malley, E. D. Everett, H. C. O'Malley, and E. W.
Campion. Identifying and Preventing Family Mediated Abuse
and Neglect of Elderly Persons. Annals of Internal
Medicine, 1983.
M. G. Ory. The Burden Of Care. Generations, Quarterly
Journal of The American Society on Aging, 10:14-17, 1985.
H. C. O'Malley, H. Segars, R. Perez, V. Mitchell, and G. M.
Knuepel. Elder Abuse in Massachusetts: A Survey of
Professionals and Paraprofessionals. Technical Report,
Legal Research and Services for the Elderly, Boston,
1979.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
H. J. Parad. Crisis Intervention. In Encyclopedia Of Social
Work, Volume I. National Association of Social Workers,
Washington, D.C., 1971.
E. Pfeiffer and E. W. Busse. Mental Disorders in Later Life
- Affective Disorders: Paranoid, Neurotic and Situational
Reaction. In Mental Illness in Later Life. American
Psychiatric Association, Washington, D.C., 1973.
V. Pedrin and S. Brown. Sexism and Ageism. Obstacles to
Health Care for Women. Generations, Quarterly Journal of
The American Society on Aging, 4:20-21, 1980.
C. Pepper. Opening Statement: Elder Abuse: A National
Disgrace. Hearing before the U.S. Select Committee on
Aging, Subcommittee on Health and Long Term Care, May 10
1985.
K. Pillemer and D. Finkelhor. Domestic Violence Against the
Elderly: A Discussion Paper. A paper prepared for the
Surgeon General's Workshop on Violence and Public Health,
Oct 27-29 1985.
L. R. Philips. Abuse and Neglect of the Frail Elderly at
Home: An Exploration of Theoretical Relationships.
Journal of Advanced Nursing, 3:379-392, 1983.
E. Pizzet. Scream Quietly Or The Neighbors Will Hear.
Penguin Books, Baltimore, 1974.
D. F. Polit and B. P. Hungler. Nursing Research: Principles
and Methods, 3 edition, J.B. Lippincott, Philadelphia,
1987.
M. J. Quinn and S. K. Tomita. Elder Abuse and Neglect.
Springer Verlag, New York, 1986.
L. Rapoport. The State Of Crisis: Some Theoretical
Considerations. Social Service Review, 36:211-217, 1962.
E. Rathbone-McCuan. Intergenerational Family Violence and
Neglect: The Aged as Victims of Reactivated and Reverse
Neglect. Presented at International Conference of
Gerontology, Japan, November 1978.
E. Rathbone-McCuan. Elderly Victims of Family Violence and
Neglect. Social Casework, 61:296-304, 1980.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
E. Rathbone-McCuan. Older Women: Endangered but Surviving
Species. Generations, Quarterly Journal of the American
Society on Aging, 6:11-12, 1982.
J. Steuer and E. Austin. Family Abuse of the Elderly.
Journal of the American Geriatric Society, 28:372-37 6,
1980.
M. G. Schmidt. Failing Parents, Aging Children. Journal of
Gerontological Social Work, 2:259-268, 1980.
D. J. Sonkin and M. Durphy. Learning to Live Without
Violence. Volcano Press, San Francisco, 1982.
M. E. P. Seligman. Helplessness. W. H. Freeman, San
Francisco, 1975.
E. Stark, A. Flitcraft, D. Zuckerman, A. Gray, J. Robinson,
and W. Frazier. Wife Abuse in the Medical Setting: An
introduction to Health Personnel. National Clearinghouse
on Domestic Violence, Washington, D.C., 1981.
M. A. Strauss, R. Gelles, and S. K. Steinmetz. Behind Closed
Doors: Violence in the American Family. Anchor/Doubleday,
Garden City, New York, 1980.
T. S. Szaz and M. H. Hollander. A Contribution to the
Philosophy of Medicine: The Basic Models of the Doctor-
Patient Relationship. Archives of Internal Medicine,
97:585-592, 1956.
E. Salend, R. A. Kane, M. Satz, and J. Pynoos. Elder Abuse
Reporting: Limitations of Statutes. The Gerontologist,
25:347-349, 1985.
T. Sommers. Caregiving: A Woman's Issue. Generations,
Quarterly Journal of the American Society on Aging, 10:9-
13, 1985.
B. F. Steele and C. B. Pollock. A Psychiatric Study of
Parents who Abuse Infants and Small Children. In The
Battered Child. University of Chicago Press, Chicago,
1968.
S. K. Steinmetz. Battered Parents. Society. 15:54-55, 1978.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
S. K. Steinmetz. Dependency, Stress and Violence between
Middle-Aged Caregivers and their Elderly Parents. In
Abuse and Maltreatment of the Elderly. John Wright PSG,
Boston, 1983.
M. Thobaben and L. Anderson. Reporting Elder Abuse: It's the
Law. American Journal of Nursing, 85:371-374, 1985.
F. M. Torres-Gil. The New Aging. In The Three Forces of
An Aging Society. Auburn House, Westport, CT, 1992.
U.S. Bureau of the Census. America in Transition: An Aging
Society. In Current Population Reports, Number 128 in P-
23. Government Printing Office, Washington, D.C., 1983.
U.S. House of Representatives Select Committee on Aging.
Elder Abuse: An examination of Hidden Problems. Technical
Report Comm. Pub. No. 97-277, 97th Congress, Government
Printing Office, Washington, D.C., 1981.
L. E. Walker. The Battered Woman Syndrome. Springer, New
York, 1984.
J. M. Weiner. Can Long-Term Care Expenditures for the
Elderly be Reduced? The Urban Institute. June, 1996.
J. M. Weiner, L. H. Illston, R. J. Hanley. Sharing the
Burden: Strategies for Public and Private Long-Term Care
Insurance, The Brookings Institution, Washington, D.C.
1994.
J. T. Weston. The Pathology of Child Abuse. In The Battered
Child. University of Chicago Press, Chicago, 1968.
R. S. Wolf, M. A. Godkin, and K. A. Pillemer. Elder Abuse
and neglect: Final Report from Three Model Projects.
Technical Report, University of Massachusetts Medical
Center, 1984.
R. S. Wolf and K. A. Pillemer. Working with Abused Elders:
Assessment, Advocacy and Intervention. Technical Report,
University of Massachusetts Medical Center, Worcester,
MA, 1984.
R. S. Wolf and K. A. Pillemer. Helping Elderly Victims: The
Reality of Elder Abuse. Columbia University Press, New
York, 1989.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
S. W. Zarit, K. E. Reever, and J. Bach-peterson. Relatives
of Impaired Elderly: Correlates of Feelings of Burden.
The Gerontologist, 10:649-655, 1980.
123
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
APPENDIX A
Adult Protective Services Code Sheet
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
County cf uQ S anGE lE S
o e p a b t m e n t o f f u b u c s o c i a l s e r v i c e s
A D U L T PR O TECTIVE SE R V IC E S C O D E SH EET
Tne following cedes are used to com plete case records, legs and reports for the Adult Protective Services
program
ADULT PRO TECTIVE SERVICES SCREENER'S EVALUATION (PA 1978)
Language C odes:
1 Scanish 7 English
2. C hinese 15 Arm enian
3 Japanese 13 Cam bodian
a Korean 03 Lao
5 Tag a'cg 6 3 Vietnam ese
Ethnic Codes:
1 . W hite 2. Hispam c
3. Black not cl Hispanic origin
a Asian cr Pacific Islander
5 A m erican Indian cr Alaskan Nat.ve
7 Filipino
Alien Status Codes:
0 U S C'tioen
: Legal Resident-less than five years
a Legai Resident-five years or longer
5 Undocum ented Alien
Refection Codes:
1 . C lient is neither im paired ncr endangered
2. C lient is im paired but not endangered
3 C lient is aoie to resolve endangerm en:
4 O ther-expiain
Tyoes of Abuse
r r t y S . C S i
Sexual
Negiec:
Aoanconment
Mental Suffering
riCuCiary
Pnys.cai (includes Setf-Negiec
= CuC-.ary
Suicicai
Referral Reason Codes:
Eider Abuse
Perpetrated
by Others
I . ' 2 3
1/25
1/27
1/2S
1/3*
'32
Self-Inflicted
Eicer Acuse
3 - J
Dependent Adult Abuse
Perpetrated by Others
2/2-:
2/25
2 '2 5
2/3G
2 '32
2 '3 -
Self-lnflicted
Dependent Adui: Acuse
a 33
a AC
Referral Source Codes:
E :g:ci-:ty W crva-
2 i.-3 S C S V /C .C tner CPSS Sra'f
- Sen.cr C ilice'S F rc g 'am /A g en cy
c v s.tmg Nurse "-o m e .-e a rn A g e— oy
•Z Z ^ r* ' — ' *5 * • £ '• ? ' - '•**’ Z? * 3 “ ZC
' -o s c ita i M eo.cai Ctm.c
c M ;r :a i-eaitn C b u n se'-n g jC en:e-
'U se wnen la-.v enforcem ent persenn.e1 is crigmai reocr
enforcem ent :re reierrai source is m e cany tnat comacre
•sa"j;o ss. i }is ; a. ,„ i io,
f O ther Pucl.c Agency 'Ent ty
2 O ther Private Agency
A. Nevgnccr Pnenc
5 P J 1 3 • ; o i f ; -
~ Fe*at-'*e "ct -r :-•»
7 O te r :
6 Ctri'Sr .'Arcr.yrr.CLS. rc.v^
r.g aarfy ’:re 'a-.v enforc-erre^; _____
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
AOULT PROTECTIVE SERVICES SERVICE PLAN (PA 1970)
Resources/Supportive Services Codes:
7. Out-of-Hom e Placem ent.
Adjustment. Transfer
2. Nursing H om e/B oard
& Care t&R
3. INFO Line
4. Law Enforcement
5. Criminal Justice System /
Legal Services
6. HcSO'tal/ClihiC
7. OrugfAlconol program
a . Mental Health Services
9. LPS Conservatorship
7 0. Probate Conservatorship
r r. Phys.cian/Oentis:
7 2. Visiting Nurse/
Public Health Nurse
73. Regional Center
7 4. Senior Citizens' Services
7 5. IHSS Assistance
7 0. Other OPSS Program
7 7. Temporary Sneiter
73. Fooc/M eal Program
7 9. School/Vocational Training
20. Veterans Services
2 f.
lD/O ocum ent procurement
22. Community Agency (ether
than shelter)
23. Clothing
24. Em ployment Services
25. Social Security
Administration
26. Imm igration and
Naturalization Service
27. O tner Government Agency
23. N eighbor cr Friend of
Client
29. Landlord/M anager
30. Fam iiy M em cer
3 7. Community Transportation
32. O ther
AOULT PROTECTIVE SERVICES CONTROL LOG (PA 1972)
t. Care Custodian 6
2 . Health Practitioner 7
3 Parent 8
4 Ottsoring 9
c
Scouse
Susoected A buser Codes:
Other relation
No relation
Unknown
Sell
t . Unable to locate client
2. Unable to gam access
to client
3. Client refused services
а. Client not in danger
5. No APS needed
б. Client deceased
7. Accepted for LPS/
Probate Conservatorship
Reason for Closing Codes:
a .
Accepted by another
agency
9. Services Completed -
Problem resolved
to. Services Completed -
Problem unresolved
11. Client moved out of county
12. Other
Evaluation/Investigation Outcome Codes:
1 7 Reserved for future use.
3 7 Reserved for future use
2 S Reserved for future use.
4 3 Reserved for future use.
S 1 7 Eider Abuse by O thers - APS Investigated. Confirmed
9 IS Self-inflicted E lcer Abuse - APS Investigated. Confirmed
1 0 /13 Dependent Adult Abuse by Others - APS Investigated. Confirmed
i O' 20 Self-inflicted D ep en d en t Adult Asuse - APS investigated. Confirmed
i i Eicer Apuse by Self or Others - APS Investigated. Not Confirmed
12 Oeoencent Adult Abuse by Self or Others - APS Investigated. Not Confirm ed
M
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
IMAGE EVALUATION
TEST TARGET (Q A -3 )
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i n
S S 5 S
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I.25
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150mm
IFS/1/4C3E . In c
1653 East Main Street
Rochester. NY 14609 USA
Phone: 716/482-0300
Fax: 716/288-5989
O 1993. Applied Image. Inc.. All Rights Reserved
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Asset Metadata

Creator Keswani, Akanksha N. (author)

Core Title Elder abuse crisis intervention techniques and their effectiveness

School Leonard Davis School of Gerontology

Degree Master of Science in Gerontology

Degree Program Gerontology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Gerontology,health sciences, public health,OAI-PMH Harvest,Social work

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Wilber, Kathleen (committee chair), Larue, Gerald (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-18824

Unique identifier UC11342305

Identifier 1389986.pdf (filename),usctheses-c16-18824 (legacy record id)

Legacy Identifier 1389986.pdf

Dmrecord 18824

Document Type Thesis

Rights Keswani, Akanksha N.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA