Abstract and Keywords
Elder abuse is now recognized internationally as a social problem among the aging population. Intentional abuse, neglect, and exploitation among caregivers to frail and isolated elderly create serious risks across diverse formal and informal care settings. This field has expanded continuously since the early 1970s. Accurate prevalence and incidence rates have not been determined. There is a national system of elder victim protection operating within each state. The social work profession is legally mandated to report situations where an elderly person is suspected to be at risk of abuse. Social workers are involved in all aspects of elder abuse prevention and intervention services.
The field of elder mistreatment, often generalized as elder abuse, encompasses two conditions. According to the comprehensive analysis prepared by the National Research Council (2003), there are important distinctions between intentional actions that cause harm or create serious risks of harm by a caregiver and unintentional failure by a caregiver to meet the elder's basic needs or protect him or her from harm. The condition of self-neglect occurs from action or inaction by an individual elder that cannot be attributed to actions of another person but may produce harm and risks because of the lack of self-care (Pitt, 2011). Victimization of elder persons by a stranger falls into the realm of criminal behavior that is not associated with a caregiver's action or failure to act. Elder abuse among persons who reside within institutional care settings is another distinct form of endangerment that manifests as individual patient victimization or as a generalizable risk to an entire facility population, and response systems are addressed separately from community domestic settings (Daly, 2011; Frying, Summers, & Hoffman, 2006).
Since the 1980s there has been increasing attention to forms of elder maltreatment. However there remains no national consensus over the definition of elder abuse (Stolee, Hiller, Etkin, & McLeod, 2012). Variations in the definitions of elder abuse occur based on many factors depending on specific application of the definition. Legalistic definitions flow from the terminology within statutes. Research definitions are developed in conjunction with the purpose and study questions directing the investigation. Policies that govern program design and service provision often drive definitions based on the specific type of abuse and the immediate risks the elder faces. Additionally, there is lack of funding for this type of research, with vast methodological variation, paucity of theory-grounded investigations, and perpetual small sample researches that are not generalizable (Teaster, Wangmo, & Anetzberger, 2010). There is, however, widespread consensus that the problem creates the potentiality of harm that can lead to death (Hildreth, Burke, & Golub, 2011). The severity and complexity of cases has prompted the exploration of elder abuse forensic centers (Navarro, Wilber, Yonashiro, & Schneider, 2008; Wiglesworth, Mosequeda, Burnight, Younglove, & Jeske, 2006). Intentional abuse will continue to increase with the demographic shifts of a rapidly aging population, and it is of growing concern in the United States and in many other countries (Podnieks, Penhale, Goregen, Biggs, & Han, 2010; Brownell, 2006). Estimates of elder abuse prevalence and incidence suggest that between one and two million aged persons have been subject to intentional mistreatment (National Center on Elder Abuse, 2005). The continuing lack of reliable national epidemiological studies is a serious limitation in the field. Currently it is impossible to know how widespread elder abuse is within the elderly population and speculation about the actual number of cases emerges from expert opinion (Cooper, Selwood, & Livingston, 2008).
Wolf and Pillemer (1989), Pillemer and Finkelhor (1988), and Blenkner, Bloom, Nielsen, and Weber (1974) offer some of the earliest analyses on elder abuse risks. These initial projects generated a sufficient number of cases where the caregiver was not meeting the elder's major needs on purpose. From these few cases the investigators identified an aspect of intentionally harmful caregiver behavior toward the elder. Their work has been expanded in subsequent studies of the risk associated with elder mistreatment. Repeatedly confirmed risk factors associated with community-based domestic elder care settings include living arrangement, cognitive or physical impairment, mental illness and substance abuse characteristics among perpetrators, and caregiver social, emotional, or financial dependency on the elderly person. It has been suggested, but not well validated, that gender, race, intergenerational family abuse histories, and many other factors contribute to greater or lesser risk (National Center on Elder Abuse, 2005). Acierno (2003) provides an overview of key studies that have elucidated elder mistreatment risk factors. These represent clusters of risk that pertain to the elder's condition, specific characteristics of the harming caregiver, and the historical and current relationship between them.
The pursuit of causal theory to explain elder abuse has relied on the application of other theoretical areas such as the cycle of violence, psychopathology, social exchange, and family stress. Development of causal conceptual frameworks rigorously tested through empirical approaches and evidence-based investigations remains an ongoing challenge to better understand this phenomenon (Lowenstein, 2010). In a case-by-case analysis, aspects of different theories related to intentional harm may seem to apply as reasons for the elder mistreatment. These theoretical applications are not satisfactory for explaining elder mistreatment as a growing social problem among the aged population. More recently, the Panel to Review Risk and Prevalence of Elder Abuse and Neglect under the auspices of the National Research Council (2003) proposes a more detailed model for understanding elder mistreatment that involves a transactional process unfolding over time among the elder person, his or her trusted other, and other interest parties (stakeholders) concerned with his or her well-being in the context of changes in the physical, psychological, and social circumstances of the several parties as the result of the elder person's aging process and life course. Critical concepts in this framework are social embeddedness between victim and perpetrator, status inequality between them, power and exchange dynamics in the relationship, and the outcomes of the relationship transactions. The outcomes of elder mistreatment may be recurrent, episodic, or crisis-focused, contributing to physical, mental, or social harm.
Application of the sociocultural context of elder mistreatment has been essential for gaining knowledge about elder mistreatment among major U.S. minority groups (Beach, Schulz, Castle, & Rosen, 2010; Briana, 2009; Parra-Cardona, Meyer, Schiamberg, & Post, 2007; Rapoza, Cook, Zaveri, & Malley-Morrison, 2010) and contributes to understanding at the international level. Over time, the exploration of elder abuse among African American, Hispanic, Asian American, and American Indian communities in the United States has helped to slowly improve the quality of culturally competent elder abuse intervention strategies (Rittman, Kuzmeskus, & Flum, 1999). This has increased in accordance with the early recommendations of Moon and Williams (1993). They suggest the urgent need for attention to a definition of elder abuse that is culturally specific for different ethnic groups. Small sample, descriptive design studies have contributed a beginning clarification of intra- and intergroup similarities and differences applicable for intervention and prevention services (Huber, Nelson, Netting, & Borders, 2007).
There is an increasing amount of published information from research on elder abuse in many different countries, encouraged by such organizations as the World Health Organization (WHO) and other international networks of elder abuse prevention, which emphasize the sociocultural and political-economic contexts of elder victimization. Of particular importance is the preliminary research in developing nations where problem recognition and professional and community concerns have the potential to influence the development of services. Some of the poorest regions in India (Evans, Kiran, & Bhattacharyya, 2011) and the countries in Africa (Ferreira, 2005) are attempting to build on village or tribal community resources so as to offer better protection to the most vulnerable elders. In these efforts ancient values and traditions of “honoring the elders” are being rekindled with contemporary community conditions and family transformations. In 2002, the WHO sponsored one of the first international projects to define attitudes and perception of elder abuse involving both developed and developing nations.
Prevention and Treatment Models
Public adult protective services (APS) are the backbone of elder mistreatment reporting, investigation, and assessment. The passage of Title XX Block Grant to States for Social Services and Elder Justice of the Social Security Act in 1974 opened a federal funding channel to states for the development of APS. Some states capitalized quickly by tapping into federal resources, while other states elected not to devote block grant resources for this service provision.
As states implemented APS, these units were typically located within larger departments and divisions addressing aging concerns, public health concerns, and family-focused social services. By the early 1980s all states had public service units that delivered APS. Yet there has never been a uniform APS delivery model among states and there are no uniform definitions of abuse, neglect, or exploitation. Each state developed statutes that broadly defined the age range and mental and physical disability status of persons to be covered, as well as the conditions of elder abuse, neglect, and exploitation. With a few exceptions, professional categories of mandated reporters were identified and required to report suspected cases of potential elderly persons thought to be at risk. For those working as advocates for greater federal involvement by way of legislation and funding, the continued underfunding for elder abuse compared to child abuse and violence against women remains a critical concern.
Elder abuse is an expanding focus of attention and area of service delivery. Health care, criminal justice or law enforcement, and social services systems are all being required to address the physical, social, and economic risks that combine to create serious harm to elderly victims. While APS remain the predominant source of elder victim reporting, investigation of case detection occurs in diverse sectors of interaction with aged individuals. Because of multiple risks, the types of harm, and the dimensions of perpetration, multiple systems must be engaged and their efforts coordinated. Collaboration occurs through both formal and informal mechanisms. A number of multidisciplinary intervention teams working with individual cases—as well as local- and state-level task forces, coordinating councils, and coalitions to address elder abuse—are increasing (Brandel et al., 2007; Schneider, Mosqueda, Falk, & Huba,2010).
Roles of Social Work
The social work profession does not have proprietary claim to the prevention or intervention aspects of elder abuse; however, social workers assume a major role at the micro and macro levels in all facets of this growing social calamity (Imbody and Vandsburger, 2011). Social workers are the predominant professionals in APS and provide critical services and help prevent harm or offer follow-up services to meet the victim-care needs. They deliver clinical services and help caregiving families resolve crisis situations (McCreary, 2012). Some social workers have contributed extensively to the field through the publication of case studies documenting the conditions of risks and harm, the reduction or elimination of these, and the steps taken for positive resolution as applicable (Dayton, 2005). From these studies the field has identified threads of critical information about the range of an elder's vulnerabilities, the relationship structures and functions between victim and perpetrator, the critical components of case investigation and assessment, and the advocacy processes needed for policy and program development. Elder abuse prevention advocacy should involve constant monitoring of caregiver mistreatment behaviors. Vigilance is essential by older people as well as those who provide them with formal services and are committed to their overall well-being. Advocacy for more effective governmental policies, expanded resources for coordinated comprehensive programs, and community elder safety education is essential (Anetzberger & Teaster, 2010; Huber et al., 2007).
A challenge that social workers face in elder mistreatment problems relates to the difficulties associated with the empirical investigation needed to establish a process and outcome model of best social work practice. The profession is, however, beginning to make major strides in anticipatory preparation to meet the needs of the currently old and the millions now rapidly aging in society.
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