Service Provider Perspectives on Family Violence Interventions (1995)

Service and prevention programs in the field of family violence have developed separate approaches for children, spouses, and the elderly. Elder abuse is the most recently “discovered” form of family violence, and its nature and dimensions are not well known. In some cases, elder abuse represents spousal abuse that has simply remained chronic over an extended period of time, and the violence may be discovered only when an injury is apparent. In other situations, elder abuse may be the result of an adult child who has moved back home with a frail parent, possibly as a caregiver, and who exploits the financial or other resources of the parent who may be able to offer only limited resistance.

As noted in a recent report (Reiss and Roth, 1993), elderly victims are disproportionately over age 75. They are more vulnerable to victimization because of illness or impairment and they often reside with the perpetrator of abuse. Women outnumber men as victims, but the research studies have not yet taken into account women's greater risk exposure because of their longer life expectancy. However, illness or impairment of the victim may not be the major risk factor for elder abuse. Research in this field, though not well developed, suggests that there may be different forms of elder abuse, only one of which may be dominated by risk factors suggesting victim frailty or vulnerability.

Intervention programs focused on elder abuse are extremely limited, and only a few innovative efforts have been developed. The workshop speakers emphasized the importance of recognizing the complex dimensions of elder abuse and understanding the need to balance competing principles in this field, such as the safety of senior people as well as their autonomy in making decisions about their personal living circumstances.

Reiss, A.J., Jr., and J.A. Roth, eds. 1993 Understanding and Preventing Violence, Vol. 1. Committee on Law and Justice, Commission on Behavioral and Social Sciences and Education, National Research Council. Washington, D.C.: National Academy Press.

Georgia Anetzberger

Much of what is known about interventions on behalf of abused elders comes from anecdotes. There has been little research undertaken to identify various strategies used to prevent and treat elder abuse and even less to assess their efficiency and effectiveness. Theoretical models for formulating interventions have been proposed, but not validated (Phillips, 1986; Pillemer, 1986). Treatment models have been described, but rarely evaluated (Crouse et al., 1981; Quinn and Tomita, 1986; Fulmer and O'Malley, 1987).

The need for research on elder abuse prevention and treatment is widely recognized, and several national research panels have identified areas for exploration (Family Research Laboratory, 1986; Stein, 1991). These areas include evaluation of:

• mandatory reporting,

• state protective service programming,

• identification and screening methods,

• criminal justice strategies, and

• experimental design.

Most panels, however, prioritize the need to evaluate adult protective services, which is widely regarded as the core or pivotal intervention system concerned about elder abuse in the home (Bergman, 1989; U.S. House Select Committee on Aging, 1990).

Authority for adult protective services is usually derived from state law and is centralized in state departments of human services or their equivalent (American Public Welfare Association and National Association of State Units on Aging, 1986). The adult protective model has five components (Burr, 1982):

• report receipt;

• situation investigation;

• case-plan development;

• protective service provision; and

• case monitoring, reassessment, and termination.

This model dominates community response to domestic elder abuse nationwide and reflects the origin of problem recognition and subsequent evolution of intervention strategies.

Public recognition of elder abuse began in the 1950s with concern about the “protective client,” which preceded the mid- to late-1970s writings of Robert Butler (1975), the testimony of Suzanne Steinmetz (1978), and the research of Elizabeth Lau and Jordan Kosberg (1979) and others. After World War II, federal agencies, such as the Social Security Administration and Veterans Administration, and social workers, attorneys, and physicians, became alarmed about the large numbers of older people who were handicapped, living outside of institutions, and subject to neglect and exploitation because they could not care for themselves and no one was able or willing to take care of them (Lehmann and Mathiasen, 1963; Hall, 1971).

In the wake of conferences, research, and demonstration projects on the elderly population during the 1960s, a profile of the protective client appeared (Hall 1973; Ferguson, 1978), not unlike the profile for the contemporary stereotypic elder abuse victim (Milt, 1982; Council on Scientific Affairs, 1987). Major characteristics of the protective client include elderly nonmarried females (over age 75) who are mentally incapacitated, physically impaired, have a low income, are unable to self-care, and lack adequate care from others.

A pattern of intervention also emerged. The protective service system, as it was called, emphasized the need for a constellation of preventive, supportive, and surrogate services. It stressed safety over freedom, the importance of interdisciplinary diagnostic study, and the potential transfer of decision-making authority from a client to a guardian, conservator, or other designee (American Public Welfare Association, 1962; O'Neill, 1965; U.S. Senate Special Committee on Aging, 1977; Regan, 1978).

Interest in protective services waned during the early 1970s. Part of this can be attributed to legal and ethical questions raised about the conflict between protective intervention and individual rights (Horstman, 1975; Hobbs, 1976; Regan, 1979). Skepticism over the role of protective services also resulted from the findings of program evaluation projects, such as that undertaken in Cleveland, Ohio, by The Benjamin Rose Institute, which suggested that protective services led to higher rates of institutionalization and death among clientele (Blenkner et al., 1971). Although questions have now been raised about flaws in the original research design and methodology of this project which render the findings questionable (Dunkle et al., 1983), they presented a restraint to program growth in the 1970s.

Although somewhat discredited, protective services did not disappear, primarily due to federal funding through Title XX of the Social Security Act of 1974 and early enactment of state protective laws. As a result, the protective services system was well positioned for the second wave of public recognition about elder abuse, which occurred during the late 1970s, when protective services became the intervention of choice at the

time as advocates sought a system to address elder abuse in its multiple forms. Three characteristics of protective services made it particularly attractive:

1. It had demonstrated flexibility in expanding its target population. During the 1950s the main emphasis of protective services was on the extremely mentally incompetent adult. This population was enlarged in the 1970s under Title XX to include the marginally incapacitated adult as well. Abused elders easily fit into this broadening framework.

2. It incorporated the use of legal intervention in problem treatment. No characteristic so distinguishes protective services from other intervention strategies for the aged as the potential use of legal action (Huttman, 1985). That abused elders may require legal assistance made protective services seem like an appropriate vehicle for service linkage.

3. It was well established nationwide. Therefore, abused elders could be handled within the context of an existing service system, avoiding the difficulties and costs of forming a new one.

The state of Ohio illustrates this phenomenon. Many of the social workers and attorneys who drafted the Ohio Protective Services Law for Adults in 1980 had worked in adult protective services. They believed that public welfare services, available throughout the state, had long experience handling both abused children and adult protective clients and could therefore deal with the needs of abused elders. In the momentum of social action, they gave little thought to the fact that Ohio's public system of adult protective services had never been evaluated. Likewise, they did not question the appropriateness of expanding the definition of protective clientele to include all abused elders without empirical study on the effectiveness of this intervention mode in dealing with physical abuse and other types of maltreatment. Among the states, only Illinois and North Dakota evaluated various programs before instituting a statewide model.

Since 1980 a number of studies have been undertaken to advance our understanding of elder abuse and programmatic responses to it (e.g., Anderson and Theiss, 1989; Fredriksen, 1989). Perhaps the most exhaustive of these studies was funded by the Administration on Aging to investigate three model projects along the East Coast. Among its salient findings for response to domestic abuse are the following:

1. Different types of elder abuse reveal different victim/perpetrator profiles (Wolf et al., 1986). This suggests the need for variation in intervention strategies and services. Yet a number of factors deter this approach, including state law and administrative code, resource scarcity, professional orientation, and personal bias.

2. Organizational structure does not seem related to client outcome. Three models were explored: service brokerage, coordinating, and mandatory reporting. Of these, only service brokerage had a unique outcome. Because workers using this model had more extensive involvement in client services, they also had a greater tendency to regard situations as unresolved (Wolf and Pillemer, 1984). Although this can be viewed variously, one set of implications suggests the potential for intake limitations, case backlogs, and client dependency.

3. Necessary but scarce resources for effective intervention include emergency shelter, respite, legal services, and home health care (Wolf et al., 1982). However, even when these resources are available, they often are not designed to meet the needs of abused elders. For instance, battered women's shelters in Cleveland sometimes have second-floor bedrooms and no elevators and lack essential medical and personal care services. Respite volunteers have not been trained to deal with the dynamics of abusive situations in the home, and most legal assistance focuses on advocacy for entitlement rather than intervention on behalf of elder abuse victims. Of the four resources identified, only home health care includes abused elders among its targeted populations, which is reflected in the specialized training for home health aides.

4. The greatest perceived barrier to effective service provision is lack of receptivity on the part of victims or perpetrators (Wolf et al., 1982). In Ohio, 15 percent of abused elders who are reported to authorities and found in need of protective services refuse services (Ohio Department of Human Services, 1985-1994). One important area for study is the impact of service refusal. Does it actually have negative consequence for the elder in terms of further endangerment or health deterioration? Does service refusal reflect assertion of self-determination with positive consequence for mental health?

Other research has supported these findings. For example, several studies have echoed the complexity of abuse dynamics and need for flexible intervention strategies (Giordano and Giordano, 1983; Anetzberger, 1987; Bristowe and Collins, 1989), and the Pennsylvania Elder Abuse Prevention Project identified similar service gaps (Fiegener et al., 1989).

Another study that illustrates an attempt to examine service delivery to abused elders involved an analysis of data collected through the Illinois Department on Aging (Sengstock et al., 1990). Three important conclusions emanate from this work:

1. Elder abuse victims are offered the same type of services available to the frail aged.

2. Victims are more likely to receive extensive services if workers are familiar with their type of abuse.

3. There is a greater tendency for workers and agencies to become involved in self-neglect than physical abuse situations.

These findings can be interpreted in many different ways. One approach is based on the original concept of the protective client, who resembles the frail aged or self-neglected elder familiar to workers in the study just described. There is a long

history of dealing with this type of individual, and, therefore, there is greater comfort and more services available. Physically abused elders tend to be recent additions to the client caseload. Consequently, many workers are struggling to identify appropriate interventions for them. Also, the social taboo associated with physical abuse against the elderly presents workers with another barrier to overcome in case investigation and service provision.

These findings reveal a bias in service focus on the victim, not the victim-perpetrator dyad, extended family, or even the abusive act itself. As a result, few intervention strategies are directed at the perpetrator. In addition, there has been greater reliance on formal than on informal services in dealing with abused elders. Although several authors have encouraged a family or caregiver orientation in elder abuse prevention and treatment (Edinberg, 1986; Steinmetz, 1990), this orientation is not commonplace. Nevertheless, the effectiveness of one approach over another has not been determined and is an area for future inquiry.

As already noted above, adult protective services has been evolving since the 1970s. Over the years national and local conferences and networks have provided opportunities for information exchange, mutual support, and dissemination of “best practice” techniques and updates on the state of the art in elder abuse research (Bernotavicz, 1982; Inter-Organization Coordination Projects, 1986). In addition, the philosophical orientation of protective services has changed over time from safety over freedom to freedom over safety (Hornby, 1982; Astrein et al., 1984; Anetzberger and Miller, 1995). In Cleveland, the emphasis on freedom is so great among public protective service workers that they are sometimes criticized for not doing enough, since case analyses found only 13 percent of elder abuse situations resulted in protective placement, a restrictive form of intervention (Harel et al., 1989).

Finally, funding for adult protective services has declined during the past decade, largely due to inflation and cuts in Title XX (now called the Social Services Block Grant). Only a handful of states enacted elder abuse reporting or protective service laws with accompanying appropriations, and additional sources of revenue, such as county levies, have been minimal (U.S. House Select Committee on Aging, 1990). Since a funding decline has occurred at the same time that elder abuse reporting has increased and the complexity of abuse situations has become recognized (Tatara, 1990), many workers and agencies have become overextended and frustrated in addressing this problem (McLaughlin, 1988).

The evolution of adult protective services can be seen in programs at The Benjamin Rose Institute (BRI). BRI is a nonsectarian, voluntary agency that provides health, social, and residential services to older adults and their caregivers. BRI is designated as a protective service provider under Ohio's Protective Services Law for Adults and was one of eight original demonstration sites for adult protective services in the late 1960s.

BRI's model of adult protective services has several characteristics that provide an advantage in handling elder abuse situations when compared with many public agency counterparts. Relying on an endowment and multiple government and private funding sources, BPI is able to offer an interdisciplinary team approach to protective assessment and intervention. Six clinical teams have social workers and nurses as professional staff along with home care aides, case manager assistants, and senior companions as paraprofessional staff. Legal and psychiatric consultants as well as contract therapists and a nutritionist are available to the clinical teams. The result is multiple perspectives for better quality diagnosis and service provision along with shared responsibility for reduced worker isolation and burn-out in handling difficult case situations.

The BPI model of adult protective services allows the agency to remain involved with clients beyond the problem identification and crisis intervention stages, which offers a means of prevention for future reoccurrence of elder abuse. The diversity of services, which range from adult day care to housekeeping to mental health counseling, provides responses for the various needs of protective clients internally, without necessary reliance on other community agencies. The agency 's endowment enables them to serve individuals for which there is no reimbursement source.

Three other characteristics of adult protective services at BPI deserve attention. First, an Elder Abuse Consult Team has been established that is available to staff twice monthly, or more often, if requested. Composed of advanced-level administrative and clinical staff with extensive experience in adult protective services, the Team provides outside perspective, guidance, and support for especially complex client situations.

Second, there is a standard orientation for new staff that includes use of a preferred risk assessment tool, clients' rights considerations, and appropriate application of legal interventions. There is also advanced training offered to all staff on an annual basis on new intervention strategies and ethical issues. The orientation and training are essential if staff are to have the knowledge, skills, and confidence to undertake protective services.

Third, BRI participates in several local elder abuse networks, where communication, collaboration, and comradeship can occur across organizations and systems. These networks include Protective Services Designated Agencies Group, Western Reserve Consortium for the Prevention and Treatment of Elder Abuse, and Ohio Coalition for Adult Protective Services.

BRI works through these networks with various agencies to improve the response to elder abuse in Greater Cleveland and throughout the state, particularly in the areas of community education, legislation, and program development.

BRI's current endeavor is a Community Dialogue Series on Ethics and Elder Abuse. This series involves 20-30 professionals across multiple disciplines and systems meeting monthly over a six-month period to discuss such issues as:

• Should elder abuse perpetrators be regarded as people with problems or as criminals?

• Should behavior be labeled elder abuse when the ethnic group involved does not label it as such?

Public protective service agencies face many challenges that offer a stark contrast to the experience of a voluntary protective service agency such as BRI. Public protective service agencies are routinely placed in the position of being unable to select cases and receive cases that other agencies have rejected (Quinn and Tomita, 1986). The unrealistic expectation that public protective service agencies can and should do anything and everything has diluted their capacity for effective intervention and impedes their ability to maintain reports and investigations, provide adequate services, and offer follow-up to prevent the reoccurrence of elder abuse. Heavy caseloads, insufficient staffing, and inadequate training for staff have led to stigmatization against public protective services in some locales.

In addition, because of limited resources, many public protective service agencies have been unable to hire staff or consultants from other disciplines, which precludes in-house multidisciplinary assessment and intervention and leaves those undertaken by social work alone subject to criticisms of limited perspective (Johnson, 1991).

The criminalization of elder abuse, which began in the mid-1980s, has helped shift elder abuse intervention from social services to the criminal justice system in some states. This shift has left many public protective services workers confused and insecure over their jurisdiction (Harshbarger, 1989), which may hamper their ability to adequately address the problem of elder abuse overall (Formby, 1992).

Finally, elder abuse has increasingly captured the attention of the Older Americans Act Aging Network. Recent reauthorizations of the Act have resulted in greater role and resources for the Aging Network in abuse prevention. At the federal level, this has brought about cooperation between the Administration on Aging, the American Public Welfare Association, and the National Association of State Units on Aging to establish the National Center on Elder Abuse. Unfortunately, cooperation of this magnitude has not always occurred at other levels, leaving some state and local departments of social services and aging pursuing independent courses of action in their attempt to impact elder abuse.

Our society is only beginning to understand elder abuse as an aspect of family violence and health problems affecting older Americans. Effective interventions can be developed by examining and evaluating different strategies in different communities, but the search will require changing our laws, systems, and approaches as a result.

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Anderson, J.M., and J.T. Theiss 1989 Making policy research count: Elder abuse as a legislative issue. Pp. 229-241 in R. Filinson and S.R. Ingman, eds., Elder Abuse: Practice and Policy. New York: Human Sciences.

Anetzberger, G.J. 1987 The Etiology of Elder Abuse by Adult Offspring. Springfield, Ill.: Charles C Thomas.

Anetzberger, G.J., and C.A. Miller 1995 Impaired psychosocial functioning: Elder abuse and neglect. Pp. 518-552 in C.A. Miller, Nursing Care of Older Adults: Theory and practice,2nd ed. Philadelphia, Penn.: J.B. Lippincott.

Astrein, B., A. Stinberg, and J. Duhl 1984 Working With Abused Elders: Assessment, Advocacy, and Intervention . Worcester: University Center on Aging, University of Massachusetts Medical Center .

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Bernotavicz, F. 1982 Community role. In Improving Protective Services for Older Americans: A National Guide Series. Portland: Human Services Development Institute, University of Southern Maine .

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Burr, J.J. 1982 Protective Services for Adults: A Guide to Exemplary Practice in States Providing Protective Services to Adults in OHDS Programs Washington, D.C.: U.S. Department of Health and Human Services.

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Crouse, J.S., D.C. Cobb, and B.B. Harris 1981 Abuse and Neglect of the Elderly in Illinois: Incidence and Characteristics, Legislation, and Policy Recommendations. Springfield: Sangamon State University and Illinois Department on Aging.

Dunkle, R.E., S.W. Poulshock, B. Silverstone, and G.T. Deimling 1983 Protective services reanalyzed: Does casework help or harm? Social Casework 64:195-199 .

Edinberg, M.A. 1986 Delivery and integrating family-oriented approaches in care of the elderly. Pp. 267-282 in K.A. Pillemer and R.S. Wolf, eds., Elder Abuse: Conflict in the Family. Dover, Mass.: Auburn House.

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Fiegener, J.J., M. Fiegener, and J. Meszaros 1989 Policy implications of a statewide survey on elder abuse. Journal of Elder Abuse and Neglect 1(2):39-58.

Formby, W.A. 1992 Should elder abuse be decriminalized? A justice system perspective . Journal of Elder Abuse and Neglect 4(4):121-130 .

Fredriksen, K.I. 1989 Adult protective services: Changes with the introduction of mandatory reporting. Journal of Elder Abuse and Neglect 1(2):59-70.

Fulmer, T.T., and T.A. O'Malley 1987 Inadequate Care of the Elderly: A Health Care Perspective on Abuse and Neglect. New York: Springer.

Giordano, N.H., and J.A. Giordano 1983 Individual and Family Correlates of Elder Abuse. Paper presented at the annual meeting of the Gerontological Society of America, San Francisco.

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1973 Guide to Development of Protective Services for Older People. Springfield, Ill.: Charles C Thomas.

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Pillemer, K.A. 1986 Risk factors in elder abuse: Results from a case-control study. Pp. 239-263 in K.A. Pillemer and R.S. Wolf, eds., Elder Abuse: Conflict in the Family Dover, Mass.: Auburn House.

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Rosalie S. Wolf

A review of the elder abuse literature more than 15 years after the first report was published discloses an appalling lack of well-designed research, especially when compared with the output for child and spouse abuse over a similar time period. This paucity may be due as much to difficulties in conceptualizing the problem as to lack of funding or investigator interest. While child and spouse abuse attracted the attention of established scholars in psychology, sociology, medicine, and other disciplines early on, elder abuse did not have the same appeal even for gerontologists (Lachs and Pillemer, 1995); in fact, one gerontologist several years ago labeled elder abuse a “dying non-issue” (Callahan, 1986).

Some disinterest might be traced to the complexities of the concept and inconsistencies in the definitions. Elder mistreatment encompasses a range of behaviors from physical abuse to psychological oppression, financial exploitation, neglect, and self-neglect. It can occur in a variety of family and institutional settings and be perpetrated by children, spouses, family members, trusted friends, or caregivers. Although there is consensus about the broad categories (physical, psychological, financial, and neglect), there is less agreement about what the terms represent. Variation both in the classification of types of mistreatment and in the manifestations of each type has compromised the validity and reliability of research efforts. Ethical considerations and confidentiality issues also serve as barriers to undertaking research in this field.

Generally, studies have been primarily exploratory or descriptive. The early studies were valuable in substantiating the existence of the problem. Later efforts helped to characterize the victims, perpetrators, and the abusive situations and to identify risk factors. In the intervening years, only one metropolitan area prevalence study of elder abuse has been carried out, and a national incidence study has just begun. Two studies on elder abuse are currently being funded by the National Institutes of Health; four in total since elder abuse first emerged as a problem. One is examining the perceptions of elder abuse held by middle-aged and older adults residing in seven culturally diverse counties in North Carolina. The other is identifying risk factors for elder mistreatment using state adult protective service agency cases that are also part of a community cohort for whom detailed physical, psychological, and social

status information has been gathered over a 10-year period. Needless to say, only a handful of studies have focused on the assessment of interventions.

Given the multiple facets of elder mistreatment, there is a wide array of interventions. Hospitalization and temporary shelter are the more common immediate responses with nursing home placement for more long-term resolutions. In cases that are primarily a result of caregiving stress, helping the caregiver is the treatment of choice. This help includes bringing into the home skilled nursing, homemaker assistance, personal care, meals-on-wheels, chore services, friendly visitors, and respite care; placing the victim in adult day care; and enhancing the ability of the caregiver to cope through counseling, stress management, or skill-building.

When the cases involve physical abuse and an abuser (primarily an adult child) who is dependent financially and/or emotionally on the victim, another avenue of intervention is indicated such as helping the abuser through vocational counseling, job placement, housing assistance, alcohol and drug treatment, mental health services, and financial support and counseling for the victim. Since physical and financial abuse situations are often criminal or civil offenses, interventions may be through the criminal justice system. Legal instruments such as orders of protection, restraining orders, or temporary commitment papers are used, but incarceration of the abuser is rare. Elderly persons are extremely reluctant to press charges against children or spouses, and more often than not, abusers are not willing clients. Court-ordered counseling programs, such as those for wife batterers, do not exist in elder abuse, although several new programs for older battered women and men are organizing support groups for abusers.

In searching the literature for program evaluation studies, seven were located that used experimental or quasi-experimental design or inductive statistics. Five were funded by the Administration on Aging, one by private foundations, and one with state funds. The group of seven includes three studies that measure the effectiveness of delivering protective services and four that address specific programs.

1. Elder Abuse and Neglect: Final Report from Three Model Projects (Wolf et al., 1984; Wolf and Pillemer, 1989).

   This report evaluated and compared three programs (in Massachusetts, New York, and Rhode Island) in terms of casework process, interagency coordination, model replicability, and client outcome measured by changes in manifestations of abuse and level of risk. Data were obtained from project staff and community agency personnel interviews, two surveys of community agencies a year apart, baseline and 6

month assessments of 328 clients, and a comparison of 42 physically abused clients and matched nonabused clients (Wolf et al., 1992; Wolf and Pillemer, 1994).

2. An Evaluation of Four Elder Abuse Projects (Wolf et al., 1992; Wolf and Pillemer, 1994).

   This project is a four-phase study of elder abuse programs (Hawaii, California, Wisconsin, and New York) based on the three-model project methodology described above. Again, data were obtained from project staff and community agency personnel interviews, two surveys of community agencies a year apart, baseline and 6-month assessments of 121 clients, and a comparison of 53 abused clients and matched nonabused clients.¹

3. Determining Effective Interventions in a Community-Based Elder Abuse System (Quinn et al., 1993).

   This study analyzed the change in risk level of 537 clients in the Illinois protective services system using a statewide risk assessment protocol² based on 23 risk factors and caseworkers' judgments about case closure.

4. A Statewide Elder Abuse Prevention Program (Baumhover et al., 1988; Scogin et al., 1989).

   This program, held in community mental health centers in Alabama, sponsored an eight-session caregiver training program for individuals who had abused or were at risk of abusing the person in their care. Three groups were studied: an intervention group (56), a delayed intervention group (16), and a no-intervention group (23). Criteria included changes in level of anger, self-esteem, cost of care, and psychiatric symptoms.

5. Evaluation of Guardianship/Conservatorship: An Institutional Diversion National Demonstration Project(Wilber, 1990).

   This evaluation studied a money management program offered as an alternative to guardianship to 60 persons referred by Adult Protective Services and the Office of the Public Guardian in Los Angeles. A randomized experimental/control design was used. Outcome measure was institutionalization.

6. Comparison of Paid vs. Volunteer Multidisciplinary Teams in Providing Community-Based Care to Elder Abuse Victims (Stahl and Hwalek, 1990).

   This demonstration program was conducted in two rural and two urban communities in Illinois and included a comparison of having a team or no team on reducing caseworker burn-out.

7. An Evaluation of a Program of Volunteer Advocates for Elder Abuse Victims (Filinson, 1993).

   This evaluation was designed to assist victims in the utilization of the criminal justice system. A matched sample (28) drawn retrospectively from the program files

Although these studies are an improvement over the first generation of elder abuse research because they are prospective, use control groups, and interview victims directly, the methodology used in all of them would not meet rigorous scientific standards. Most of the samples are too small, data collection processes are subject to biases, and groups are not randomly drawn.

Good research in elder abuse will require the involvement of skilled investigators, increased funding, and active cooperation and partnership of practitioners. Effective intervention strategies will depend on more basic knowledge about the nature of the problem, greater understanding of the causal and contextual factors, and better diagnostic tools. Most services for abused and neglected elders are offered through state-administered, supervised, or contracted programs. At a minimum, states need to update their information systems so that program evaluation will be possible. Several states are in the process, most notably Texas, where a paperless system is being developed in conjunction with its child protective services. Illinois is probably ahead of most states in using research and evaluation to design its delivery system with state funds as well as grant money. More federal dollars should be available for demonstration projects, information systems, and research. Although the National Institute on Aging has designated elder abuse as an area for investigation, a stronger commitment is needed in the form of a specific allocation.

¹Analyses of client data are still in progress.

²The Risk Assessment Form used by the Illinois Department on Aging was developed and validated as a client risk assessment by the State of Florida.

Baumhover, L.A., F.R. Scogin, N.P. Grote, C. Beall, G. Stephens, and J. Bynum 1988 A Statewide Elder Abuse Prevention Program. Tuscaloosa: College of Community Health Sciences, University of Alabama.

Callahan, J.J. 1986 Guest editor's perspective. Pride Institute Journal of Long Term Home Health Care 5:2-3 .

Filinson, R. 1993 An evaluation of a program of volunteer advocates for elder abuse victims. Journal of Elder Abuse and Neglect 5(1):77-94.

Lachs, M., and K. Pillemer 1995 Abuse and neglect of elder persons. New England Journal of Medicine 332(7): 437-443 .

Quinn, K.M., M. Hwalek, and C. Stahl-Goodrich 1993 Determining Effective Interventions in a Community-Based Elder Abuse System. Springfield: Illinois Department on Aging.

Scogin, F., C. Beall, J. Bynum, G. Stephens, N.P. Grote, L. Baumhover, and J. Bolland 1989 Training for abusive caregivers: An unconventional approach to an intervention dilemma. Journal of Elder Abuse and Neglect 1(4): 73-86 .

Stahl, C., and M. Hwalek 1990 Comparison of Paid vs. Volunteer Multidisciplinary Teams in Providing Community-Based Care to Elder Abuse Victims. Springfield: Illinois Department on Aging.

Wilber, K.H. 1990 Material abuse of the elderly: When is guardianship a solution? Journal of Elder Abuse and Neglect 2(3-4): 89-104 .

Wolf, R.S., and K. Pillemer 1989 Helping Elderly Victims: The Reality of Elder Abuse. New York: Columbia University Press.

1994 What's new in elder abuse programming? Four bright ideas. Gerontologist 34(1): 126-129 .

Wolf, R.S., M.A. Godkin, and K.A. Pillemer 1984 Elder Abuse and Neglect: Final Report From Three Model Projects. Worcester: University Center on Aging, University of Massachusetts Medical Center .

Wolf, R., K. Pillemer, and S. Frankel 1992 Advances in the Treatment of Abused and Neglected Elders: Results From Two Community Surveys. Worcester: University Center on Aging, University of Massachusetts Medical Center .

Mary Cay Sengstock

As public recognition of elder abuse increases, more professionals have become aware of their responsibility to recognize victims and help them receive assistance. Some professional organizations, such as the Joint Commission on the Accreditation of Healthcare Organizations, now require guidelines for the management of elderly people in hospitals. This fact has motivated some hospitals to train their staff and make the care of the elderly a high priority.

Yet major improvements are still needed. The categorical systems approach to services often makes it difficult to arrange the type of comprehensive or specialized care that elderly victims require. Many cases demand long-term intensive work that is very expensive. Services need to be coordinated, and some important services (such as nutritional care, transportation, or recreational opportunities) are not available. Since many agencies have not yet adopted training programs or policies on this issue, referrals often involve informal arrangements with knowledgeable people rather than contracts with organizations. Furthermore, few opportunities exist for in-depth research or training to help participants evaluate and improve their programs.

Most practicing professionals have no training in elder abuse. In 1990, under a grant from the Administration on Aging, a set of training materials was developed for instruction of health and social service professionals in the identification and management of elder abuse victims and their families. The materials were developed by myself and Dr. James G. O'Brien, Department of Family Practice, Michigan State University School of Medicine (Sengstock and O'Brien, 1990).

Over the past five years, Dr. O'Brien and I have made numerous presentations in Michigan and in other states drawing on these materials. On several occasions we have been joined by attorneys, social workers, and nurses who provide a special expertise in the area of state laws or available social services. In these presentations we refer to the Elder Abuse Screening Test (Hwalek and Sengstock, 1986; Neale et al., 1991) and the Comprehensive Index of Elder Abuse (Hwalek and Sengstock, 1986a,b), which I developed with my colleague Melanie Hwalek. These materials detail techniques of identifying abused elders, and the Comprehensive Index of Elder Abuse also suggests possible service mechanisms.

The training materials have been incorporated into a training program that is available through the Michigan State University School of Medicine (Sengstock et al., 1990). The initial part of the training program is an introduction to elder abuse, which

includes physical abuse and neglect, psychological abuse and neglect, and financial exploitation. The program focuses on the behaviors and demographic characteristics that distinguish elder abuse from child abuse, physician experience with elder abuse, and the positive and negative features associated with family care of elders.

Most of the training is practical and stresses the early indicators of abuse, so that practitioners can learn to identify elderly victims of abuse before they are seriously injured, become gravely ill, or die. The program includes an introduction to state and local laws regarding abuse, reporting requirements, and related issues such as durable power of attorney and guardianship. Faculty stress detailed features of case management, including attention to family and caregiver dynamics, general approaches, role of other professionals, and suggestions for how to interview victims, abusers, and caregivers.

Hwalek, M.A., and M.C. Sengstock 1986a Assessing the probability of abuse of the elderly: Toward development of a clinical screening instrument. Journal of Applied Gerontology 5(2):153-173.

1986b Comprehensive index for assessing abuse and neglect of the elderly . Convergence in Aging 3(1):41-64.

Neale, A.V., M.A. Hwalek, R.O. Scott, M.C. Sengstock, and C. Stahl 1991 Validation of the Hwalek-Sengstock elder abuse screening test. Journal of Applied Gerontology 10(4):406-418 .

Sengstock, M.C., J.G. O'Brien, A.M. Goldynia, T. Trainer, T.G. deSpelder, and K.W. Lienhart 1990 Elder Abuse Assessment and Management for the Primary Care Physician .Michigan State University College of Human Medicine, Office of Medical Education Research and Development, East Lansing.

Sengstock, M.C., M.R. McFarland, and M.A. Hwalek 1990 Identification of elder abuse in institutional settings: Required changes in existing protocols. Journal of Elder Abuse and Neglect 2(1):31-50 .

Henry Blanco

The Elder Rights and Disabled Adults Unit within the Aging and Adult Administration in Arizona includes four statewide programs: Adult Protective Services (APS), Long Term Care Ombudsman, Legal Services Development, and the Benefits Counselor program. In Arizona the typical APS client is a female aged 75 years or older who lives alone on a low income. Ethnicity is fairly representative of the state's general population.

In most states, the APS programmatic framework is developed by state legislation. Since federal laws do not define elder abuse or establish criteria for APS, each state defines its own target populations. All state APS programs do include the elderly either by definition or intent and include abuse, neglect, and exploitation as general criteria for state involvement. Arizona law originally defined adults who were incapacitated as the target population for APS services, but in most cases the client is at risk due to age or physical or mental limitation even though they are not legally incapacitated. As a result, state law was amended to include “vulnerable” adults. Approximately 60 percent of the APS cases in Arizona are listed as “self-neglect, ” which means that the client is at risk because of his or her own actions or lack of action, rather than the actions of others.

The goal of the APS program is simple, but complex: to prevent or alleviate the abuse, neglect, or exploitation of incapacitated or vulnerable adults. The program recognizes the principle that competent adults have the capacity and the constitutional right to make decisions, including the right to refuse services and intervention, regardless of caseworker opinions of the clients or their lifestyle. This right may be removed through a long and legal process for the assignment of a guardian, if the vulnerable adult is determined to be unable to make decisions that protect his or her own self-interest. State officials need to balance their responsibility to intervene with the individual's right for self-determination, which may involve protecting a client who chooses not to be protected.

Arizona APS program officials give priority to the protection of the client's autonomy and the client's right to remain in control of his or her own destiny. The caseworker has a responsibility to be certain that the client is aware of options, understands these options, and has the capacity to make a decision. If these factors exist and the client refuses to initiate changes, the responsibility is to accept that decision. This process often places the caseworker in the position of protecting the

client from those who wish to force change in the interest of serving the client's needs. As a result, APS may often be seen as “doing nothing” by a community that desires change.

Throughout this process, the assessment of the client's competence and incapacity becomes a critical issue. Arizona courts generally require a physician's statement before considering a petition for guardianship, but the caseworker's role in the assessment process is also critical. In order to minimize the influence of the caseworker 's own bias and personal values, APS programs are developing a Risk Assessment form to standardize the assessment process.

The development of this form requires extensive time. The reliability of the original design and methodology were field tested by a series of 60 intake interviews by pairs of APS workers representing both rural and urban areas. The results of the field test suggested that the percentage of agreement among the raters was far from unanimous when major scales of abuse, neglect, and exploitation were calculated. As a result, efforts are continuing to standardize definitions used in the assessment process.

Successful intervention is difficult to define. Since the APS goal is to protect the client's autonomy and right to self-determination, a successful outcome may mean allowing the client to live in a neglectful situation. It may also mean removing an abusive family member from the home. In some cases, however, this family member may be the sole source of transportation or other support, and the public service delivery system is unable to replace those services.

State officials are exploring opportunities at the state and federal level for coordination of intervention services. Title VII of the Older Americans Act, which includes Allotments for Vulnerable Elder Rights Protection Activities, provides funding for activities in this area and requires a systematic and coordinated approach to address these problems. In Arizona we have sought to implement this approach by the development of Elder Rights Process Improvement groups which involve major stakeholders in this area, such as the Attorney General 's office, and representatives of the medical, educational, and social service communities.

One important model of interagency collaboration in Arizona is the Medigap Information and Referral Initiative, which was developed to provide health insurance information to senior citizens to ensure that they receive their benefits and to protect them from insurance fraud and abuse. This initiative was developed by the Arizona Department of Economic Security, Aging and Adult Administration, which recognized the need for accurate and readily accessible insurance information. The Department was committed to provide such services through the State Plan on Aging. Funding for the initiative was provided in 1992 by the Health Care Finance Administration and the National Information and Referral Support Center of the National Association of State Units on Aging. The first step was to establish an 800-hotline phone service for eight months. The National Committee to Preserve Social Security and Medicare donated a computer and printer to record Medigap insurance data and to prepare special reports.

The Medigap Information and Referral Program in Arizona plans to develop the following services as part of its effort:

• Counseling to persons needing health insurance information including assistance in filing claims and obtaining benefits; policy comparisons, claim assistance, and rate information; assistance regarding long-term care, home health care, and related efforts; and information regarding alternative health care plans, other health insurance, and potential eligibility for Medicaid benefits.

• Systems of referral to appropriate state and federal agencies for health or insurance-related problems.

• Training programs for staff members, volunteers, and requesting organizations.

The challenges in developing intervention efforts often reflect the difficulty of responding to the client's wishes, especially when the client does not want intervention, or when change may not occur despite our intervention. Training of social service, legal, and medical providers is paramount in this area.

In cases when the client does accept intervention, access to and availability of services become important issues. Interventions can be expensive and extremely limited in some areas. For example, a 75-year-old abused spouse who requires shelter may not find a shelter capable of handling her special needs. In cases where legal testimony is necessary for successful prosecution of offenders, elder abuse victims may not be reliable witnesses to the events because of their age and condition.

Finally, elder abuse needs to be viewed beyond the parameters of child abuse. Many state laws addressing elder abuse were developed by simply incorporating the term “elder” into existing child abuse legislation, and elder abuse programs have suffered from the lack of resources for staff and program development.

Service providers in health, social service, and legal settings who address the problems of elderly populations must consistently strive to balance the goals of sustaining independence and autonomy for elderly clients, reducing the costs of intervention services, and establishing safe and supportive caretaking environments for elderly people. Victims of elder abuse frequently may be physically or financially dependent on their abuser, and those who seek to protect them may not be in a position to assure adequate care if the abuser is removed from the home.

American society lacks a clear definition of caretaker responsibility for elders comparable to parental responsibilities for children. If a caretaker is a financial guardian, this arrangement requires certain contractual obligations. Failure to observe these obligations may provide a basis for legal interventions, but opportunities for involvement by the criminal justice system are very limited in the field of elder abuse. This may be an area that is appropriate for evolution of civil law, but few efforts have been initiated to address the existing problems.

Research on the demographics of elder abuse suggests that an elder is likely to be abused by the person with whom he or she lives (Pillemer and Finklehor, 1988). Since more elders live with their spouses than with their children, more elders are abused by spouses, but the difference in abuse rates between those who live only with their children (44/1,000) and those who live only with their spouse (41/1,000) are not significantly higher. Abused elders are as likely to be male as female, although most of the intervention services appear to focus on elderly women as their primary clients.

Public health nurses identify many elder abuse cases because of their access to private homes. Nurses may seek to intervene when they consider their clients' environments to be dangerous. One opportunity for such intervention is when nurses eliminate their services and thus force their clients to be institutionalized. Local fire departments are also often called in response to elder abuse cases, but they may have little training in intervening in such situations beyond providing emergency care. Police officers are increasingly being reminded to look for abused children when they respond to incidents of domestic violence, but little attention has been given to the need to look for abused elders. Finally, focus group discussions involving several generations and four ethnic groups revealed that elderly people are often more frightened of psychological abuse than physical abuse or financial exploitation, yet

public service agencies have almost no training or resources to deal with this area of abuse.

Topics that deserve further consideration in the evaluation of elder abuse service programs include the topics to be covered in training programs, barriers to change that exist in different target populations, points of recruitment and resistance among service providers, and the identification of components of practice or training that deserve evaluation.

Pillemer, K., and D. Finklehor 1988 Prevalence of elder abuse: A random sample survey. Gerontologist 28(1):51-57.