Illness, age, and disability render people vulnerable to abuse by those on whom they depend for care and protection. Abuse is an age-old crime that takes many forms: physical, psychological, sexual, and financial. It is a hidden form of mistreatment, occurring in private homes, adult daycare, and long-term care institutions. Adult abuse is far less likely to be reported than child abuse because of lack of public awareness. Abuse is “an intergenerational concern, as well as a health, justice, and human rights issue” (Lowenstein, 2009).

The maltreatment of children and of dependent adults (elders and other vulnerable adults) is a social issue as well as a public health issue and it presents problems for the entire community. Achieving the goals of intervention, protective services, and prevention requires the coordination of many resources. Both types of abuse share many things in common but there are some distinctions that will be discussed throughout the course.

Child Abuse and Neglect

Federal legislation lays the groundwork for state laws on child maltreatment by identifying a minimum set of actions or behaviors that define child abuse and neglect (CWIG, 2019).

The Federal Child Abuse Prevention and Treatment Act (CAPTA) (amended and reauthorized in 2010), defines child abuse and neglect as, at a minimum, “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation (including sexual abuse as determined under section 111), or an act or failure to act which presents an imminent risk of serious harm” (42 U.S.C. 5101 note, § 3) (CWIG, 2019; ACF, 2017).

Additionally, it stipulates that “a child shall be considered a victim of ‘child abuse and neglect’ and of ‘sexual abuse’ if the child is identified, by a State or local agency employee of the State or locality involved, as being a victim of sex trafficking (as defined in paragraph (10) of section 7102 of title 22) or a victim of severe forms of trafficking in persons described in paragraph (9)(A) of that section” (42 U.S.C. § 5106g(b)(2)) (CWIG, 2019).

Most federal and state child protection laws primarily refer to cases of harm to a child caused by parents or other caregivers; they generally do not include harm caused by other people, such as acquaintances or strangers. Some state laws also include a child’s witnessing of domestic violence as a form of abuse or neglect (CWIG, 2019).

Types of Child Abuse

Abuse and neglect of a child by a parent, caregiver, or other person in a custodial role (eg, clergy, coach, teacher) are actions that result in harm, potential for harm, or threat of harm to the child. The four common types of abuse and neglect are:

• Physical abuse—intentional use of physical force such as hitting, kicking, shaking, or burning
• Sexual abuse—pressuring or forcing a child to engage in sexual actions including fondling, penetration, or exposure to other sexual activities
• Emotional abuse—behaviors that harm self-worth or emotional well-being such as name calling, shaming, rejection, withholding love, threatening
• Neglect—failure to meet basic physical and emotional needs of housing, food, clothing, education, and access to medical care (CDC, 2019; CWIG, 2019; ACF, 2017).

Most states recognize these four major forms of maltreatment. Many also classify abandonment, parental substance use, and human trafficking as abuse or neglect. As a way of addressing the abandonment of infants many states have passed “safe-haven” laws that allow the surrender of a newborn infant up to a certain age under specific conditions where the parents are exempt from charges of abandonment or abuse (CWIG, 2019; ACF, 2017).

Consequences

Effects of child abuse and neglect are both immediate and long term. Cuts, bruises, and broken bones, along with emotional or psychological problems such as impaired development and anxiety may be easily apparent, but left untreated or experienced chronically this maltreatment can lead to increased risk of injury, future violence victimization and perpetration, substance abuse, sexually transmitted infections, delayed brain development, reproductive health problems, involvement in sex trafficking, non-communicable diseases, lower educational attainment, and limited employment opportunities (CDC, 2019; CWIG, 2019, 2019a).

These physical, psychological, behavioral, and societal consequences affect abused children’s present and future lives but can also affect the lives of unborn children. Recent research has found that abused children may experience genetic changes associated with a variety of physical and psychological disorders (CWIG, 2019a).

The monetary costs to society are not inconsequential. Centers for Disease Control and Prevention (CDC) researchers used 2015 data on child maltreatment costs to develop cost estimates that included both tangible costs (eg, child welfare, health care, juvenile justice) and intangible costs (eg, pain, suffering, grief).

The estimated lifetime cost for non-fatal incidents of child maltreatment is $831,000 per child, and for fatal incidents, it is estimated to be $16.6 million per child. Researchers appraised the annual cost of nonfatal child maltreatment in the United States to be $428 billion (based on the number of substantiated cases of nonfatal maltreatment) or $2 trillion (based on the number of investigated instances of nonfatal maltreatment) (CWIG, 2019a).

Obviously, the mistreatment itself is foremost, but government agencies have a duty to assess the costs of public health problems. In the United States the total lifetime economic burden of child abuse and neglect rivals that of other high-profile public health problems, such as stroke and type 2 diabetes (CDC, 2019).

Incidence and Prevalence

Child abuse and neglect are regrettably not uncommon, with approximately 1 in 7 children experiencing them in the last year, and this is believed to be an underestimation. The rates of child abuse and neglect are 5 times higher for children in families with low socioeconomic status as compared with those of higher socio-economic status (CDC, 2019).

Nationally, the 2017 Child Maltreatment Report, published by the Children’s Bureau (part of the Administration for Children & Families of the U.S. Department of Health and Human Services, or DHHS), indicates that the (national, rounded) number of children who received a child protective services investigation response or alternative response increased 10% from 2013 to 2017. While the number of victims has varied over the last 5 years, the number increased 2.7% between 2013 and 2107 (CB, 2017).

Of the 2017 victims, 74.9% were neglected, 18.3% were physically abused, and 8.6% were sexually abused. Some victims suffered only one type of maltreatment while others were subjected to two or more. In 2017 an estimated 1,720 children died of abuse and neglect, which is 2.32 per 100,000 children in the national population (CB, 2017).

The most devastating outcome is the death of a child, and 72% of child fatalities involved children under the age of 3. Boys experience a higher fatality rate (2.68 per 100,000) than do girls (2.02); and, among African Americans, white, and Hispanic children, African Americans experience the highest rate (4.86) and Hispanic children the lowest (1.59) (CB, 2017).

Dependent Adult Abuse

Dependent adult abuse includes the abuse of elders (defined by the federal Older Americans Act of 1965 as anyone over 60 years of age), but it also includes maltreatment of anyone over age 18 whose physical and/or mental condition makes them dependent on others for care or protection. The term vulnerable adult is often used to encompass both groups (ACL, 2017).

The Elder Justice Act was passed in 2010 and is the first comprehensive legislation at the federal level. to address the abuse, neglect, and exploitation of older adults The law authorized a variety of programs and initiatives to better coordinate federal responses to elder abuse, promote elder justice research and innovation, support Adult Protective Services systems, and provide additional protections for residents of long-term care facilities. The Elder Justice Act established the Elder Justice Coordinating Committee to coordinate activities related to elder abuse, neglect, and exploitation across the federal government (ACL, 2017a).

Types of Adult Abuse

In general, dependent adult abuse refers to any knowing, intentional, or negligent act by a caregiver or other trusted person that causes harm or a serious risk of harm to the vulnerable adult. All fifty states have some form of law preventing elder abuse, but these laws and the definitions they employ vary considerably, so it is important to understand the specific laws of your state (ACL, 2019; CDC, 2019a; CDC, 2016; NAPSA, 2019).

Frequently recognized types of elder abuse include:

• Physical—illness, pain, or injury caused by the use of physical force such as hitting, kicking, pushing, slapping, and burning
• Sexual—forced or unwanted sexual interaction of any kind, contact and non-contact
• Emotional or psychological—verbal and non-verbal behaviors that inflict anguish, mental pain, fear, or distress and may include name calling, humiliating, destroying property, and blocking access to family and friends
• Neglect—failure to meet basic needs of food, water, shelter, clothing, hygiene, and essential medical care
• Financial—illegally or improperly using the vulnerable adult’s money, benefits, belongings, property, or assets for someone else’s benefit, can include removing money from an account without authority, unauthorized credit card use, or changing a will without permission (CDC, 2016).

Other terms that are sometimes treated as separate types or as components of those above include:

• Isolation
• Exploitation—the illegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else's benefit
• Abandonment—desertion of a vulnerable adult by anyone who has assumed the responsibility for care or custody of that person
• Self-neglect—characterized as the failure of a person to perform essential, self-care tasks and that such failure threatens his/her own health or safety (ACL, 2019).

Consequences

[This section taken largely from NCEA, 2019.]

Like child abuse, dependent adult abuse has short- and longer-term impacts. Elder abuse’s many negative impacts exist on both micro and macro levels:

Physical

• The most commonly documented physical impacts of elder abuse include: welts, wounds, and injuries (bruises, lacerations, dental problems, head injuries, broken bones, pressure sores); persistent physical pain and soreness; nutrition and hydration issues; sleep disturbances; increased susceptibility to new illnesses (including sexually transmitted diseases); exacerbation of pre-existing health conditions; and increased risks for premature death.
• Elders who experienced abuse, even modest abuse, had a 300% higher risk of death when compared to those who had not been abused.

Psychological

• Established psychological impacts include levels of psychological distress, emotional symptoms, and depression higher than those observed among elders who have not experienced these exposures.
• One study of older women found that verbal abuse only leads to greater declines in mental health than physical abuse only.

Financial

• Financial exploitation causes large economic losses for businesses, families, elders, and government programs, and increases reliance on federal health care programs such as Medicaid.
• Research indicates that those with cognitive incapacities suffer 100% greater economic losses than those without such incapacities.
• Financial abuse by itself costs older Americans over $2.6 billion dollars annually.

Social

• Social consequences may vary from increased social isolation (due to self-withdrawal or perpetrator imposition) to decreased social resources (social identities, supports, roles in key networks) and increased expenditures on services to compensate for resources lost through exploitation and to identify and rehabilitate elder abuse victims.

Hospitalizations and disability

• Victims of elder abuse are three times more likely to be admitted to a hospital.
• Elder abuse is predictive of later disability among persons who initially displayed no disability and is associated with increased rates of emergency department utilization, increased risks for hospitalization, and increased risk for mortality.

Medical costs

• The direct medical costs of injuries are estimated to contribute more than $5.3 billion to the nation’s annual health expenditures.
• Most adverse events in nursing homes—due largely to inadequate treatment, care and understaffing—lead to preventable harm and $2.8 billion per year in Medicare hospital costs alone (excluding additional—and substantial—Medicaid costs caused by the same events).

Other impacts

• Other societal costs may include expenses associated with the prosecution, punishment, and rehabilitation of elder abuse perpetrators. Estimates of such expenses are not currently available.
• Elder abuse causes victims to be more dependent on caregivers. As a result of providing care, caregivers experience declines in their own physical and mental health and their financial security suffers (NCEA, 2019).

Incidence and Prevalence

The National Council on Elder Abuse notes that experts have reported that knowledge about elder abuse lags as much as two decades behind the fields of child abuse and domestic violence. The need for more research is urgent and it requires a coordinated, systematic approach that includes policymakers, researchers, and funders (NCEA, 2019).

Research on elder abuse as proven to be especially challenging due to variations in definitions; ethical dilemmas; the unfamiliarity of Institutional Review Boards (IRBs) with elder abuse research; variations in standards and methods; reconciling different conclusions as to which type of abuse is most common; research translation; the lack of definitions of successful outcomes, which is an impediment to developing effective interventions; and finally a severe shortage of researchers (NCEA, 2019).

The NCEA notes that we simply do not know with certainty how many people suffer from elder abuse and neglect. Signs of this abuse may be missed by professionals working with the older population because of poor training and lack of awareness. In addition, elders may be reluctant to report abuse for a variety of reasons (NCEA, 2019).

The NCEA notes a several research findings of importance (2008–2015) while noting that studies use differing methodologies and definitions and may reflect regional differences:

• A comprehensive review article found the prevalence of elder abuse to be approximately 10% including physical abuse, psychological or verbal abuse, sexual abuse, financial exploitation, and neglect.
• In a study on elder abuse by family members in which data was collected by elder abuse type, researchers found that respondents most frequently reported verbal mistreatment (9%), followed by financial mistreatment (3.5%) and lastly physical mistreatment (less than 1%).
• A groundbreaking study based in New York estimated that 260,000 (1 in 13) older adults in the state of New York had been victims of at least one form of elder abuse in the preceding year. This study found that major financial exploitation was self-reported at a rate of 41 per 1,000 surveyed, which was higher than self-reported rates of emotional, physical, and sexual abuse or neglect.
• Available data from state Adult Protective Services (APS) agencies show an increasing trend in the reporting of elder abuse.
• Elder abuse is also underreported. The New York State Elder Abuse Prevalence Study found that for every case known to programs and agencies, 24 were unknown (NCEA, 2019).

Financial exploitation is a fast-growing form of abuse of vulnerable adults. In recent research, 1 in 20 elders reported recent incidents of perceived financial mistreatment, and 90% of abusers are family members or trusted others, such as caretakers, neighbors, friends, and professionals (attorneys, doctors and nurses, pastors, bank employees). Elder abuse in all forms is seriously underreported and only 1 in 44 cases of financial abuse is ever reported (NAPSA, 2019).