Abuse & Neglect

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An Overview of Abuse and Neglect

Abuse and neglect are serious problems in our communities and in our institutions. People are most at risk for abuse and neglect when they are unable to take care of themselves. Can you name the two groups of people that are least able to care for themselves? They are children and the elderly.

What exactly is abuse?

Abuse is some action by a trusted individual that causes physical or emotional harm to the victim. There are a number of different kinds of abuse including:

Physical abuse (including sexual abuse)
Emotional abuse
Financial abuse

You will learn more about each of these abuses during this inservice.

What exactly is neglect?

Neglect is when someone fails to do things that are necessary to meet the needs of a child or an elderly person. There are two types of neglect:

Passive neglect is when people don’t mean to do harm. Usually, this is because of ignorance – they just don’t know any better.
Abusive neglect is when people know better and still fail to do what is needed for the care of the child or elderly person.

You will learn more about neglect, including self-neglect, throughout this inservice.

Where do abuse and neglect happen?

Abuse and neglect happen in every community around the United States. Every day, there are children and elderly people being abused in their own homes. The abuser is usually a family member, often someone with psychological problems.

Abuse and neglect can also happen in an institutional setting, such as a day care center or a nursing home. The most common type of mistreatment in institutions is neglect. Often, these situations occur because the staff is overworked, stressed out, or poorly trained.

How much do you know about abuse?

Just take a guess, and then see the bottom of this section for the answers.

In general, victims of abuse:
1. Hate their abusers and want to report them.
2. Have very little money.
3. Exaggerate the problem.
4. Are related to the abuser.
TRUE or FALSE. Verbal abuse, such as name calling, is not really considered abuse.
Most abuse occurs:
1. In nursing homes.
2. In orphanages.
3. In people’s homes.
4. In Europe.
TRUE or FALSE. Most victims of abuse are female.
TRUE or FALSE: People who commit abuse are all alcoholics or drug addicts.
People who suspect someone is being abused should:
1. Report their suspicions, even if they might be wrong.
2. Talk to a lawyer.
3. Keep quiet unless they witness the abuse.
4. Try to get the abuser to stop hurting the victim.

Are related to the abuser. 2. False. 3. In people’s homes. 4. True. 5. False. 6. Report their suspicions, even if they might be wrong.

Facts About Abuse

Over 3 million cases of child abuse are reported every year and at least one third of them are confirmed by authorities.
In the U.S., three children die every day from child abuse and neglect. Nearly 75% of them are under three years of age.
Studies show that 1 out of every 5 children will be sexually abused in some way before they turn 18.
Child abuse and neglect costs the U.S. at least $94 billion every year.
Less than 10% of the funds spent on abuse and neglect every year go towards preventing the problem.
The average age of elder abuse victims is about 78 years.
By far, the majority of elder abuse victims are white and are abused by an adult child or spouse.

Understanding Child Abuse

Child abuse can happen in any type of family – small, large, rich, poor, white, black, etc. It can also happen to children of all ages.
Infants and toddlers are more likely than older children to be seriously injured or killed by child abuse.
Abuse to adolescents might go unrecognized, since teenagers might try to hide the problem.
Most often, children are abused by their families or guardians, but there are cases of children being abused by day care workers or other caregivers.

Abused children might react by:

Saying they deserve to be punished.
Acting frightened of parents or other adults.
Getting scared when other children cry.
Being very quiet or very aggressive.
Sitting and staring into space.
Being afraid to go home.
Acting much older than they are.
Trying to get attention by being “naughty”.
Trying to run away from home.
Getting bad grades at school.
Attempting suicide.

Neglected children might react by:

Begging for or stealing food.
Appearing in dirty or torn clothing much of the time.
Missing a lot of school.
Acting very tired all the time.
Showing no emotion on their faces.
Talking in a whisper or whine.
Trying to get attention by being “naughty”.
Abusing alcohol or drugs.
Taking on adult responsibilities.
Talking about being left alone or left “in charge” of younger siblings.

Who is at risk for child abuse?

Studies have shown that certain things put children more at risk for abuse. These factors include:

Living with a parent who has a drug or alcohol problem.
Living in a family where the parents are having marriage problems.
Being a “special needs” child, with physical and/or mental disabilities.
Living with parents who are unemployed or who have serious money troubles.
Living with a parent who was abused as a child.

Understanding elder abuse

Elder abuse is defined as harm done to persons over the age of 65 by someone who is in a position of being trusted.
There are two types of elder abuse. Domestic elder abuse happens in the person’s home. Institutional elder abuse occurs in a nursing home or other long term care setting.
Even if a caregiver or other person is trying to help, it can be considered abusive if they use enough force to cause unnecessary pain or injury to an elderly person.
We can only guess at the number of elderly who are abused every year. The best estimate is that there are about 2.5 million cases per year, but authorities say that only about 500,000 of them are reported.
Elders don’t always report the abuse because they are:
- Afraid that the abuser will find out and be angry.
- Afraid that the authorities might take their family members away.
- Ashamed that their family member is abusing them.

Signs of elder abuse

It should send up a red flag if:

The client is not allowed to speak to you unless a family member is present.
The client is punished for being incontinent.
You see family members abusing drugs or alcohol.
You hear someone threaten the client.
You hear two different stories about how the client got a bruise or other injury.
A family member refuses to allow you to complete the client’s care.

Who is most at risk for elder abuse?

Abuse can happen to anyone. However, there are certain factors that seem to increase the risk of abuse. Elderly people are more likely to be abused if:

They are physically and/or mentally impaired.
Their condition is getting worse.
They are isolated from their family or community.
They are dependent on others for all their needs.
Their caregivers are stressed out.
Their caregivers are not trained for the job of client care.
Their caregiver is a family member with emotional problems or who is addicted to drugs or alcohol.

Physical Abuse

Physical abuse is the use of physical force that may cause injury, pain or impairment. Physical abuse includes such things as:

Striking, hitting, slapping, or beating.
Pushing or shoving.
Shaking or choking.
Kicking.
Hair pulling.
Pinching or scratching.
Biting or spitting.
Burning.
Using physical restraints inappropriately.
“Restraining” someone by giving too much medication.
Taking away all food or water or forcing food.
Putting someone out unprotected in severe weather.
Using physical punishment.
Making inappropriate sexual contact.
Handling someone roughly during client care.

What are some signs of physical abuse?

Burns, including cigarette or hot water burns.
Unexplained bruises, especially bruises in the shape of a belt or fingers.
Multiple bruises that are at different stages of healing (New bruises are red, then they turn blue, then black-purple, then dark green, then yellow).
Frequent trips to the emergency room.
Cuts, scrapes, or bite marks.
Black eyes or broken eyeglasses.
Signs of sexual assault such as bruises in genital area, unexplained vaginal bleeding, and bloody or torn underwear.
Unexplained venereal disease.
Spots where hair seems to have been pulled out.
Rope marks, especially on wrists or ankles.

What can you do about physical abuse?

While you want to do your work efficiently, be careful not to hurry through it. When you rush, it’s easy to accidentally hurt someone. For example, both children and the elderly may have trouble swallowing food – and rushing them through a feeding may make them choke. Or, trying to transfer a heavy client without help may end up hurting your back and giving the client a bruise or skin tear. While you would never mean to harm your clients, rushing through your work may be seen by others as physical abuse.
Reporting a situation when you’re not sure if it’s physical abuse may seem wrong, but it isn’t. If there is abuse going on, you might save the client’s life and the abused might get some psychological help. If there is no abuse, no one will be permanently hurt by the report.

Emotional Abuse

Emotional abuse is when someone causes anguish, pain, or distress to another person by what they say or do. Emotional abuse includes things like:

Insults.
Threats.
Intimidation.
Harassment.
Yelling or screaming.
Treating an elderly person like an infant.
Constant criticism.
Refusing to listen to someone.
Giving someone the “silent treatment”.
Humiliation, such as laughing when an elderly client wets his bed.
Keeping someone away from family, friends, or the community.

What are some signs of emotional abuse?

Be on the watch for clients who:

Seem to be afraid of certain caregivers or family members.
Are yelled at by family members or caregivers.
Are made fun of by family members or caregivers.
Are suddenly very agitated.
Are suddenly confused or who are more confused that usual.
Talk about being worthless.
Cry all the time.
Never seem to get enough sleep.
Have a sudden change in appetite.
Have big changes in their weight (either up or down).
Seem very quiet or just stop talking suddenly.
Talk about being helpless.
Seem scared to talk to you about their lives or their health.
Are angry all the time.

What can you do about emotional abuse

Watch your clients for signs of emotional abuse. Don’t be afraid to discuss a situation that you think might be emotional abuse with your supervisor – even if it involves a coworker.
Avoid making jokes about your clients. It may seem like a harmless way to lighten the stress from your day, but what if the client or a family member hears you? It might be considered emotional abuse.
Maintain a positive attitude with all your clients – even if they may be “difficult”.
Report rude, disrespectful behavior toward your clients, even if it comes from a family member.

Financial abuse

Financial abuse includes the theft or misuse of someone’s money or property by a trusted individual. This includes the following activities:

Committing fraud.
Getting money by lying about why it is needed.
Forging checks.
Cashing someone else’s check without permission.
Using someone’s ATM card without permission.
Forcing someone to change his or her will.
Forcing someone to transfer property.
Keeping someone away from his or her own home or money.
Providing healthcare services to a client that are not really needed.
Promising care in exchange for money and then not following through.

Signs of financial abuse

There are some common signs that someone is being financially abused. Keep an eye out for your clients who:

Can’t pay their bills for housing, food, basic clothing, or medications even though they seem like they have enough money to do so.
Get credit card bills for stores they have never been to.
Suddenly have new “best friends”.
Talk about having to give money to others.
Seem anxious about – or don’t know – where their money is going.
Have a family member who complains constantly about how much the client’s care is costing.
Have family members who appear suddenly and claim they have a right to the client’s money.

What can you do about financial abuse?

Watch your clients carefully for signs of financial abuse. Report any suspicions to your supervisor.
Never take money from a client – even if it is offered as a gift. It may be seen by others as financial abuse.
Avoid buying food and other necessities for your clients. It’s easy to grow close to your clients and come to think of them as your family. You might see that they need help buying groceries and you want to assist them. Please remember that the best way you can help is by telling your supervisor about the client’s financial problems. There may be community services that can assist the client on a permanent basis. Otherwise, what happens to the client when you’re not there to help anymore?

Neglect

Neglect is when someone refuses or fails to take care of someone for whom they are responsible. Remember… neglect can be active, which is intentional, or passive, which is due to circumstances beyond a caregiver’s control. Examples of neglect include:

A parent who fails to take a baby for regular checkups and vaccinations.
A babysitter who runs out for a pack of cigarettes, leaving two toddlers in the home alone.
A daughter who leaves her elderly mother in the same clothes for a month.
A caregiver who refuses to help an elderly person to the bathroom.
A responsible person who deserts a child or a helpless elderly person, such as a son who drops his elderly father off at a shopping mall and never comes back.

What are some signs of neglect?

If you wonder whether a client is being neglected, keep an eye out for the clients who:

Stay in an environment that is dirty, or smells of urine or feces.
Stay in an environment that has health or safety hazards such as no heat or running water.
Have an unusual weight loss.
Have rashes, sores, or lice.
Don’t have enough clothes to stay comfortable and/or warm.
Seem poorly fed or dehydrated.
Don’t have the medications they need.
Have a dirty appearance or ripped clothing.
Are lying in soiled bed linens when you arrive.
Complain of not getting enough sleep.
Never seem to have to urinate (they may be dehydrated).
Beg for food constantly.
Have muscles that are contracted.
Have chronic bed sores.

What can you do about neglect?

Watch your clients closely for signs of neglect. Report any suspicions to your supervisor.
Follow your clients’ care plans carefully. Check with your supervisor if you don’t understand something on the care plan. If you don’t know how to perform a task, ask for help.
Take time to listen to your clients when they tell you what they need. Many of your clients depend on you for their most basic needs – food, water, comfort, and use of the bathroom. You have a lot of control over the quality of their lives, and your professional behavior will help them live happier, more comfortable lives.

Self-Neglect

“Self-neglect” is the term used for people who can’t care for themselves because of physical or mental impairments. Their behavior is a threat to their health and well-being.

For example, people who don’t have the ability to get food, shelter, clothing, or medical care for themselves may suffer from self-neglect.

However, it’s important to remember that adults have the freedom to choose how they want to live. People are not considered self-neglectful if they are mentally competent persons who understand what will happen if they do things that threaten their health – and still choose to do them.

For example, let’s say that Mr. Smith is a diabetic and has been taught about his disease. He is a competent adult and knows what will happen if he doesn’t take his insulin. If Mr. Smith still chooses not to take his insulin, he has that right – as long as he is only hurting himself and not anyone else. Because he is a competent adult, he would not be considered self-neglectful according to most state and federal laws.

What are some signs of self-neglect?

The signs that someone is suffering from self-neglect include:

Being dehydrated.
Being without food.
Freezing in the winter.
Getting overheated in the summer.
Not wearing suitable clothing for the weather.
Having bedsores.
Being very dirty or bad-smelling.
Being in generally poor health that is getting worse.
Misusing medications.
Failing to get necessary items such as dentures, glasses, hearing aids, or prosthetics.
Being unable to manage paying the bills every month.
Refusing medical attention or missing medical appointments.
Abusing alcohol or drugs.

What can you do about self-neglect?

Watch your clients carefully for signs of self-neglect. Keep in mind that many victims of self-neglect suffer from depression. For some of them, if their depression is treated, they will stop the self-neglect.
Remember that if a client is choosing to live a certain way – and is competent to make that choice – then it is not considered self-neglect.
Be sure to let your supervisor know immediately if your client:
- Talks about wanting to commit suicide.
- Says things like, “I have no reason to keep on living.”
- Tells you about a plan to commit suicide, such as using a gun or taking too many pills.

If you report your suspicions…

You may be asked some of the following questions:

Is the client in immediate danger?
Is the client in need of emergency medical treatment?
Does the client have any current medical problems?
What is the client’s current living situation?
Have you seen or heard incidents of yelling, hitting, or other abusive behavior?
Do you know the identity of the abuser?

Remember! It is not a violation of your client’s confidentiality for you to give information about the client to the people who are responsible for investigating abuse and neglect allegations.

What happens next?

If the situation is an emergency, the authorities forward the report to the police or paramedics.
The case is assigned to a staff member who contacts the victim. In some states, if the victim is a competent adult, he or she has the right to refuse an investigation.
If appropriate, the authorities will conduct an investigation of the situation. They may interview health care providers, police, clergy, neighbors, family, and friends.
Based on what the investigation shows, the victim may be moved to a safer location.
If the authorities find that it is safe for the victim to remain in his or her current living situation (or an adult victim refuses to leave) they may arrange for a variety of support, including:
- House cleaning.
- Home repairs and/or modifications, such as a wheelchair ramp.
- Medical care.
- Medications.
- Personal items and clothing.
- Caregivers and/or adult day care services.
- Food and/or food stamps.
- Home delivered hot meals.
- Mental health assessments to see if the client is capable of making decisions.
- Counseling for the victim and/or the abuser.
- Support groups for stressed-out caregivers.
- Legal services such as restraining orders that keep an abuser away from the victim or lawsuits to get back stolen funds.

Avoiding Abuse & Neglect Charges

As a health care worker, it’s important to understand how you can protect yourself against being charged with abuse or neglect. Here are some things to remember as you go about your daily work.

ALWAYS:

Follow your clients’ care plan precisely, making sure you see to all of their basic needs.
Report any signs of abuse or neglect immediately. If you don’t, you may be considered guilty of neglect yourself.
Remember that clients from different cultures may communicate their needs in different ways. Listen to your clients with both your eyes and your ears.
Know your own limits. If you feel over-stressed, talk it over with your supervisor.
Remember that anger is just one letter short of danger! Breathe deeply and count to ten if you feel yourself losing your temper during client care.
Tell your supervisor if you find yourself unable to handle a specific client. It may be that more training will help. (For example, an inservice on Alzheimer’s disease may help you understand and deal with an Alzheimer’s client better.)
Tell your supervisor if a client is refusing to eat or drink. If you forget, you could be charged with neglect.
Be a model of professional behavior for your coworkers.

NEVER:

Ignore your clients’ requests for food, water, or bathroom needs – unless what they are asking for is against physician or nursing orders. (For example, you would have to say no to a diabetic client begging you for some chocolate cake or a client on fluid restriction asking for a third glass of water.)
Keep quiet if the abuser is a coworker. While it may seem like you are “squealing” on a coworker, if you stay quiet you could be guilty of neglect. You will be helping both the client and the coworker if you speak up.
Take your personal problems out on clients. Leave your problems at home.
Let “difficult” clients get the better of you. Think of how you would feel if you had to trade places with them. Treat them with kindness and lots of patience!
Threaten or make fun of a client. Don’t stand quietly by while a coworker does it either.
Document that “the client is eating fine” if it’s not true.
“Freak out” if a client or family member accuses you of abuse when you know you didn’t do anything wrong. Discuss the situation with your supervisor, telling him or her all the facts.

Tips for Reporting Abuse & Neglect

Studies have shown that 93% of nursing assistants have seen or heard of a client being mistreated by a family member or a coworker. You and your coworkers have to work together to prevent abuse and neglect. All fifty states have laws about reporting abuse and neglect, but laws are different in each state. Check with your supervisor to learn about the abuse and neglect laws where you work.

ALWAYS:

Keep your suspicions about possible abuse and neglect confidential. Document and report the situation according to your workplace policy but don’t talk about it to anyone who doesn’t need to know.
Let your supervisor know if your client’s family members seem stressed out. (Abuse is more likely to happen when people are stressed. Your supervisor may have some suggestions for community resources to help the family members.)
Remember that keeping quiet about abuse and neglect of your clients is against the law in all but 8 states. For example, in California, if you fail to report what you know, you could be punished with 6 months in jail and a $1000 fine.
Remember that you are not expected to prove that a client is being abused or neglected. That’s up to the authorities. You are expected to report things that you have actually seen or heard that seem suspicious.
Be sure to report just the facts about a situation. For example, instead of saying, “Mrs. Smith’s daughter was drunk and she was mean to the client,” it’s better to say, “Mrs. Smith’s daughter smelled like alcohol and her speech was slurred. I heard her tell the client, ‘I wish you were dead’.”
Remember that for a report, you will probably be asked for the victim’s name, age, address, and present location, along with the situation you have observed. Some states require that you give your name and address and some don’t.
Make sure you are clear on your responsibilities when it comes to reporting abuse and neglect.

NEVER:

Jump to conclusions. Stick to the facts when reporting any client situation.
Try to solve abuse and neglect situations on your own.
Stay quiet about signs of abuse and neglect because you don’t want to get involved.
Report your suspicions without telling your supervisor first. Your supervisor is responsible for the client too.
Forget that you will not get in trouble for reporting suspected abuse – even if the authorities don’t find any abuse or the client refuses help from the authorities.

Quiz

Instructions: Take the quiz below. Your results will be recorded and sent to your supervisor.