Abuse is the violation of an individual’s human and civil rights by any other person or persons. The harm may be physical, psychological or emotional or may be directed at exploiting the vulnerability of the victim in a more subtle way. There are many different types of abuse such as physical, sexual, emotional, neglect, exploitation, discriminatory, institutional, bullying, self-harm and domestic abuse. Institutional abuse is the maltreatment of a person (often children or older adults) from a system of power. This can range from acts similar to home-based child abuse, such as neglect, physical and sexual abuse, and hunger, to the effects of assistance programs working below acceptable service standards, or relying on harsh or unfair ways to modify behavior. Institutional abuse can typically occur in a care home, nursing home, acute hospital or in-patient setting and can be any of the following discriminatory abuse
psychological and emotional abuse
Exploitation is the fact or action of treating someone unfairly in order to benefit from their work.
The main type of exploitation in health and social care is financial exploitation. Financial abuse can take many forms. For instance, title to the older person’s home or other assets is transferred to the abuser and then sold. Funds from checking, savings, and investment accounts are withdrawn without authorization. Wills are changed through intimidation. Loans are taken out and the funds given to the abuser. Checks are signed over to the abuser, who cashes them. Even outright theft of property may occur.2 It’s also about abuse of power, where carers use their role with vulnerable adults for their own gain. Eg.Sexual gain, financial gain
A suspicious care giver might misuse an elder’s personal checks, credit cards, or accounts, forge the elders signature or steal cash, income checks, or household goods. This can occur in the residential care home because the PWUS is vulnerable to trusting their health care practitioner as they seem reliable.3
Domestic violence and abuse
Any incident or pattern of incidents of controlling or threatening behavior, violence or abuse. The abuse can be: psychological
Signs and symptoms
Here are some signs to watch for:
•Bruises or injuries that look like they came from choking, punching, or being thrown down. Black eyes, red or purple marks at the neck, and sprained wrists are common injuries in violent relationships. •Attempting to hide bruises with makeup or clothing
• Making excuses like tripping or being accident-prone or clumsy. Often the seriousness of the injury does not match up with the explanation.
A nurse comes to visit a couple in domiciliary care, after couple of visits nurse notices bruising on the women when doing personal care and notices she is more withdrawn then usual and becomes defensive when the nurse asks about the bruising. Also the husband has to stay in the room when his wife’s personal care takes place and only a woman is allowed to care for his wife, else he gets aggressive towards the women
Examples of discriminatory abuse
Discriminatory abuse is mistreatment on the grounds of a person having a particular characteristic such as a differing; ethnicity; gender; age; disability; sexuality; health status; religion. Denying one individual or group the same rights as another individual or group.4 For example, someone could be assaulted due to the colour of their skin. 1 A carer looking after a person in domiciliary care, and not respecting their privacy due to them being a certain gender or race. For example, the carer going through draws/taking belongings due to a presumption about their ethnicity.
Signs and Symptom
Discriminatory abuse can include: unequal treatment due to race, gender, religion, age, sexuality or disability verbal abuse, inappropriate language, slurs, harassment and deliberate exclusion denial of basic human and civil rights e.g. allowing people to follow their own spiritual or cultural beliefs or choice about their own sexuality Indicators of discriminatory abuse may include:
lack of choice
lack of privacy and dignity
lack of personal belongings
use of punishment – withholding food and drink
Physical abuse is defined as the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. Also, inappropriate use of drugs and physical restraints, force-feeding, and physical punishment of any kind also are examples of physical abuse.
Signs and symptoms
bruises, black eyes, welts, lacerations, and rope marks
bone fractures, broken bones, and skull fractures
open wounds, cuts, punctures, untreated injuries in various stages of healing sprains, dislocations, and internal injuries/bleeding broken eyeglasses/frames, physical signs of being subjected to punishment, and signs of being restrained
Sexual abuse is defined as sexual contact of any kind with a person. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing.5 Signs and symptoms
bruises around the breasts or genital area;
unexplained venereal disease or genital infections;
unexplained vaginal or anal bleeding;
torn, stained, or bloody underclothing; and
An elder’s report of being sexually assaulted or raped.
Emotional or Psychological Abuse
Emotional or psychological abuse is defined as the infliction of pain or distress through verbal or nonverbal acts. Emotional/psychological abuse includes verbal assaults, insults, threats, intimidation, humiliation, and harassment. In addition, treating an older person like an infant; isolating an elderly person from his/her family, friends, or regular activities; giving an older person the “silent treatment;” and enforced social isolation are examples of emotional/psychological abuse.
Signs and symptoms
being emotionally upset or agitated;
being extremely withdrawn and non-communicative or non-responsive;
Neglect is defined as the refusal or failure to fulfil any part of a person’s obligations or duties. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for a vulnerable adult. For example an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care. For example, failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder.
Signs and symptoms
dehydration, malnutrition, untreated bed sores, and poor personal hygiene; unattended or untreated health problems; hazardous or unsafe living condition/arrangements (e.g., improper wiring, no heat, or no running water); unsanitary and unclean living conditions (e.g. dirt, fleas, lice on person, soiled bedding, urine smell, inadequate clothing); and An elder’s report of being mistreated.
To bully someone is where an individual uses their superior strength to intimidate or influence someone to do something that they want them to do. E.g. Bully a person with a mental illness to move or eat something if they do not want to.6
Signs and symptoms
Depending on the extent of the bullying, the signs and symptoms can be a range of physical and emotional ones.
These can include
The victim becoming withdrawn and quiet
Repeated injuries which can’t be explained such as bruises, burns or cuts
The victim showing signs of losing focus and becoming unable to concentrate
Signs of compulsive behaviour
An example of bullying in an old peoples home for dementia and Alzheimer’s: http://www.bbc.co.uk/news/uk-wales-south-east-wales-12125575 Self-Harm
Self-harm is an indicator of abuse. As a carer you should pick up on self-harm and put the appropriate/care in place to deal with issues. Legal responsibility safeguard-‘duty of care’ Deliberate injury to oneself, typically as a manifestation of a psychological or psychiatric disorder
Signs and symptoms
Unexplained cuts, bruises, burns etc. usually on wrists, arms, thighs and chest Keeping fully covered all the time, even in hot weather
Depressed nature: low mood, tearfulness, lack of motivation and interest in anything Withdrawing from others
P2: Detailed descriptions of the indicators of abuse and self-harm:
This is where the PWUS voluntarily tells you or through discussion or counselling says that they have been abused. This is an obvious indicator because it is coming directly from the person who has been abused. After the PWUS has told this information to a carer it would then be their duty to pass it on and for an investigation to take place. As a carer you have legal responsibility to report this. The incident should be further investigated because the PWUS may have a mental disability and may not understand what abuse is, therefore they may say they have been abused when in fact they haven’t. For example a person with dementia might think they are being abused but really they may just be confused. On the other hand someone may reveal they have been abused but may not reveal the full extent of the abuse. An example of where disclosure may occur is in domiciliary care where self-harm is taking place in the PWUS own home. When the carer comes to the PWUS home they may reveal to them that they are self-harming.
Changes in behaviour
This can include many different things such as confusion, trouble with sleeping, loss of confidence and expressions of anger/frustration. Changes in behaviour can easily go unnoticed because in care settings the staff are usually quite busy catering for everyone’s needs whilst trying to follow up procedures. This means staff may not notice such a change in PWUS behaviour. Some changes may be more obvious than others, for example, if there is a person who is usually quite loud, bubbly, chatty or out-going and then they become quiet, reserved, start isolation themselves and submissive then this is quite an obvious change in behaviour. An example of changes in behaviour may be in a care home where one PWUS starts to avoid a certain carer and shows fear when they are around, this may be due to this carer being abusive in the past.
Difficulties with finance
This may be easier to notice as it would be quite easy to notice if someone had taken a lump sum of money from an account however it may be hard to link it with abuse straight away. Especially if a person has given someone their trust with their finances, you may not want to believe they are abusing that trust. The indicator may be more obvious if it is a sudden change from having plenty of money to struggling with finances. This is likely to be noticed by someone who is around the PWUS when they spend their money or someone who deals with their finances.
An example for this indicator may be where a PWUS is being taken out for the day through community care and they are unable to afford their lunch even though they had plenty of money to last a couple of weeks only days before. They may go to get the money from their purse and then have nothing in there. It may also be hard to detect whether someone is being abused financially as if it’s an elderly person with dementia they may have just misplaced their money or forgotten where they have put someone. However if this happens on a regular occurrence then it might have to be put into investigation.
Stress which triggers health problems
This may be harder to link to abuse as stress can come from many different experiences and events in person’s life which can happen at any stage. Mental health problems may be depression, anxiety, dementia etc. In this situation if mental health problems are spotted there should be an investigation to make sure the real cause of this is found. This may be likely to occur in an elderly people’s home where abuse leads to stress which then makes a PWUS dementia worse. A person with dementia is already likely to be stressed as they forget things (even things like forgetting where they are) and they get confused so it would be important to look deeper into stress in case there is any unknown or undiscovered cause to the stress.
Bruises and scars are signs of abuse. These are the more obvious indicators as they are visible. A PWUS might try to hide these signs because they feel embarrassed or they might feel it’s their fault. The abuser might blame them and say that it’s their fault and make the PWUS feel shameful. For example in a care home a carer might be abusing an elderly with dementia by grabbing theirs wrists and pulling them around or hurting them and then saying to the PWUS that it’s their fault. They might say ‘no one will believe them if you tell because you’re crazy, you have dementia.
They won’t believe you; you make me do this to you’. So as you can see this would be enough to make a PWUS feel too scared to talk of their physical abuse and they may feel too embarrassed or like no one will believe them. So unexplained injuries could be a sign of abuse so if you see this it’s important to look into what caused the injury.
Poor hygiene can be a sign of abuse as it could be a sign of neglect. Hygiene could be they’re own personal hygiene like not looking and smelling clean. Or it could be their environment for example if it’s someone who is living at home but has a carer come to look after them or help them. A sign of neglect could be the house is not clean, or their duvet smells dirty and their clothes to. However it may also be where a PWUS has more difficult needs and the practitioner leaves them out to avoid catering to their difficult needs.
-not trusting other people
-becoming passive or complaint
-poor attendance at school or to social activities
-aggressive behaviour towards others
-not expressing wishes or choices
-Difficulty to pay bills
-break down in relationships
P3: Explanations of factors that may lead to abusive situations Vulnerable adults may include:
Learning disabilities: They don’t fully understand how to look after themselves and people may get frustrated because they do not understand certain things. They may have a lack of social awareness that they are being abused or treated unfairly e.g. Down syndrome goes to cinema and pays and isn’t aware of how much change they should get. Physical disabilities: They physically can’t do some things for themselves, can’t fight back when being abused. They are reliant on others for personal care, if care isn’t provided they can become neglected which may lead to infection, dehydration, malnourishment etc. Dementia: Unable to remember things which means people can take advantage of them. Memory confusion may mean the PWUS doesn’t realise they are being abused, this may tend to be financial abuse because they ae unable to keep track of their money so won’t notice if any goes missing.
Mental health needs: They are unaware of what is normal and what isn’t therefore they may think abuse is normal and they shouldn’t tell anyone about it. Due to mental distress there may be confusion or lack of understanding over the abuse taking place. Aphasia: This is similar to dementia and the memory problem may cause confusion and someone may take advantage of this. A sensory impairment: For example blind/deaf. Blind people can’t see you taking money (can’t see abuse taking place). Deaf people can’t hear verbal abuse taking place. Ill health: (cancer, diabetes) People with ill health need personal care, and they may not know how to get the help that they need. They might be open to poor quality services as desperation means they will try anything. Someone may take advantage of this desperation by charging lots of money for something that won’t work. (Practitioners making false claims) Older people: Tend to require or be reliant for personal care and managing finances therefore someone may take advantage of managing their finances by taking money for themselves. They also may be forgetful so may not notice the abuse taking place.
Environments where abuse may take place:
day care centres;
health services, e.g. GP surgeries, dental surgeries, physiotherapy
Contexts of abuse:
Adults who feel shame or fear of reporting; this may affect anyone as they may be scared of any repercussions that may happen as a result of reporting abuse. Discriminatory practice; this may affect anyone because everyone could be a victim of being discriminated against. This would occur if the person has a protected characteristic of which they are being discriminated against.
People who are dependent on others for personal care, for example physical disabilities. This may lead to abuse as the PWUS may be rough handled and/or neglected. Adults who do not have the social awareness that abuse has taken place: this may include PWUS with dementia or a learning difficulty. Financial abuse may be likely to take place as the PWUS will be unaware that their money is missing. Communication difficulties; this could affect a PWUS who is an aphasiac, has a sensory impairment or has autism. They may not be able to fight back or stick up for themselves. They also may not understand the abuse as well as struggle to report it. Social isolation; this is likely to occur with older people in their own homes or people with a mental illness because they may live alone and not go out and see friends meaning they are going without any social contact.
People with a mental illness may socially isolate themselves on purpose because they do not want to be around other people. Bullying within care services; this could also affect anyone and it is where a carer may exert their power over a PWUS to show that they are above the PWUS. It may also happen between PWUS where verbal or physical abuse is taking place. Invasion of privacy; this could also affect any of the groups and may be where a PWUS is not given privacy to get undressed or go to the bathroom etc. Relationships involving power; any of the groups
Lack of mental capacity to consent to sexual relationships: This may include people with learning difficulties and mental illness and because they can’t consent this is where sexual abuse may take place and the health or care professional may take advantage of this. Examples of people who may abuse:
Health or care professionals, those working in health or care environments, other people using services, partners, carers, relatives, friends, strangers and volunteers. Reasons why these people may abuse:
The abuse may be due to a historical cycle of abuse where ‘the abused becomes the abuser’. Being abused in the past may lead someone to think that it is okay to abuse others. People with depression/anger management issues may use their power over others to abuse. Those with anger management may be unable to control their actions in a fit of rage. Reduced mental capacity maybe due to learning difficulty or mental illness may mean they do not understand that what they are doing is abusive. They may feel as though what they are doing is not wrong as they do not know the boundaries of what is right and wrong. Poor safeguarding procedures may mean practitioners may not fully understand their role in protecting PWUS’. This means the abuse may be accidental because they are not following certain procedures correctly.
Cultural differences/first language not being English may lead to frustration and misunderstanding between a practitioner and PWUS. Poor role model in a senior member of staff may mean that any new members of staff think its common practice and that it’s okay for them to abuse the PWUS. First hand experiences of violence may lead to imitation of behaviour. Poor care from the health care professionals may be due to long hours, bringing in personal issues to work and taking it out on service users. Also being in a low paid job and being short staffed can all be contributing factors to poor care. Short staffing may mean that there is not enough time to care for all the PWUS properly. M1: Short term effects of abuse
Physical abuse can have many effects (short-term and long-term) on a PWUS and these can be physical, intellectual, emotional and social; Physical health and wellbeing is the positive functioning of body systems and the absence of illness or disease. It is getting the right amount of nutrients, activity and rest needed to function. The potential short term effects of physical abuse on physical health and wellbeing include dehydration and malnourishment from not getting enough food and water. Also injuries such as bruising, cuts, finger print marks, whiplash, friction burns. There may also be long term effects for these injuries, for example if a PWUS gets a cut during personal care and this is not dealt with then it could get infected which could, in severe cases, lead to something like blood poisoning. Long term effects of head injuries may include something such as epilepsy which is very serious and could affect the PWUS in many different aspects of their life, for example they wouldn’t be able to watch films with flashing lights or go places like carnival or fair which usually have flashing flights which could prevent them spending special days out with their families.
The potential short term effects of sexual exploitation may be injuries caused to the genital area as well as STI’s being passed on during sexual abuse which may take place in community care. PWUS with learning difficulties may be sexually abused as they would not understand what is happening and/or if it is abuse or if it is normal .This is because they don’t always know the difference between right and wrong and if the abuser is telling them its okay and normal they might not think any different as the abuser is meant to be the person caring for them. Financial exploitation could lead to the PWUS having to go without food and basic necessities as they are short of money therefore they may become malnourished.
Financial abuse may take place in care from home where the carer has a responsibility to deal with their money and finances and they slowly and sneakily transfer money into their own account or they may take cash which is lying around and then make out the PWUS is just forgetting where they have put it and take advantage. This could go easily unnoticed as there would only be one carer and its in the comfort of the elderly PWUS home so not as many people would be there to become suspicious or realise.
Intellectual health and wellbeing involves positive learning experiences which lead to skills and language being developed throughout life. Getting support to be able to learn and being mentally stimulated and challenged. The short term effects of physical abuse may include a head injury caused by the PWUS being shaken which may cause problems with cognitive processes and may cause the PWUS to become confused as well as have trouble with memory. If abusive practice is extensive enough that standard activity to stimulate intellect cannot be done by the PWUS because they may be unable to concentrate. This may lead to a fall in attendance at school/work. The short term effects of exploitation may include a PWUS being unable to focus on certain tasks due to thinking about being sexually taken advantage of.
Also with financial exploitation the PWUS may have money worries due to their money being taken from them without their permission, this may then lead to them not taking part in activities that could stimulate the brain. If a PWUS is having money taken from them in their home during domiciliary care then they may feel very confused. Also a PWUS may be exploited by not being able to be involved in certain activities as a result of the carer leaving them out, maybe because their needs are more difficult than some of the other PWUS. This may lead to them not being intellectually stimulated and stumping their development in different skills and language.
Emotional health and wellbeing includes being able to express yourself and if emotional support is required, being able to find and use this support. It is also being happy and secure in yourself as well as being in good mental health. Many emotions can arise when physical abuse and exploitation takes place and they tend to be very negative and can have negative effects on the person. Feelings of fear of the abuser are likely to occur, as a result of physical abuse. They may fear they may be abused again. If the abuse took home in a care home they may feel to scared to ever go into a care home again through the fear of being abused again. If it was sexual abuse they may feel upset and embarrassed/humiliated about the abuse. The abuser may also make the person feel as though the abuse is their fault therefore they may feel guilty and start to get a low mood which is the beginning of depression. The person being abused may become angry about the abuse as well as becoming anxious about it happening again.
This could also lead to panic attacks. Exploitation such as a PWUS being treated unfairly by being left out/not interacted with as much as other PWUS may lead to them becoming upset and lower their self-confidence. They may start to make less of an effort and become withdrawn as they will feel excluded. Financial exploitation can lead to confusion as to where money is going and upset over not having enough money for certain things. Also if the PWUS becomes aware of the financial exploitation they may feel very taken advantage of and maybe helpless that they can’t do anything about it. They may feel no one will believe them or they may feel to scared to report it as they may fear abuse afterwards. Or they may feel maybe they are just being confused because that’s whats the carer has told them so they believe it.
Social health and wellbeing is where a person has a social network of friends and family and is able to keep and form meaningful relationships. Also going out with these friends and families and enjoying yourself by taking part in different activities. Short term effects of physical abuse and exploitation on social health and wellbeing may include becoming withdrawn and not wanting to see friends and family. A PWUS, for example in a residential home, may stop wanting to participate in the activities provided and may stop interacting with other residents.
The person may stop interacting with others as well as stop making choices for themselves and allowing others to make their choices for them. This will make them loose their independency which could result in them later being taken advantage of. Also the PWUS may begin to imitate unacceptable behaviour as they have poor role models around them. Exploitation could lead to a PWUS not wanting to interact with others if they have been left out in the past or have been taken advantage of. This could lead to social isolation as they would push people away and may lose social contacts.
Strengths of spotting signs and symptoms early
The indicators or warning signs of abuse are clues that something is happening in the life of the person that should be looked into. Some indicators are obvious signs of abuse. Other indicators are subtle, requiring careful observation. In some situations abuse may not be occurring at all. It is important to think about the person and any health or behavioural issues they have. Some people may get injured more easily due to health reasons or aging. For example, some medications and some health problems like hemophilia (where the blood clots slowly) can cause easy bruising. Some people may engage in self-injurious behaviours that cause injuries that look like abuse. Even if you discover that a person has a health or behavioural issue that might be the cause of the injury, it is still important to investigate to rule out abuse as the cause. It is important to put aside any biases that you might have that care providers would not abuse a person with a disability that they support.
Courtney from Study Moose
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