Detecting and Reporting Four Types of Elder Abuse: How Official Adult Protective Services Reports Obscure Older Adults’ Self-Efficacy

It is widely held that older adults are unlikely to self-report their abusive situation to officials such as adult protective services (APS). The purpose of this study was to determine the extent to which older adults self-report or alternatively, disclose to informal sources of support who in turn place official reports. Interviews were conducted with 71 APS caseworkers, 55 of their older clients, and 32 non-abusive persons familiar with the situation. The same person who detected also reported the abuse in only 69% of the cases. While 39.5% of the older victims detected their abuse, only 18.3% also reported the abuse. The remaining older victims disclosed to someone who in turn placed a report. By listening to victim’s voices, it was revealed that at least some older adults exercise considerably more self-efficacy in their abusive situation than official reporting statistics indicate. Implications for research and policy are discussed.

Keywords: Elder Abuse; Detection; Reporting; Self-efficacy; Victim’s Voices

National prevalence studies find that at least 10% of older Americans experience some form of elder abuse each year [1], with international estimates approaching 16% [2]. Elder abuse is a rubric typically encompassing five types of abuse: physical, sexual, and psychological abuse, caregiver neglect, and financial exploitation. Research has identified a range of deleterious consequences associated with these various forms of elder abuse [3], including mortality [4].

It is widely believed that many cases of elder abuse fail to be detected [5]. In the United States, our efforts at ameliorating elder abuse have focused on mandatory reporting, at times implicitly assuming if once detected abuse will be reported. Recent research calls this assumption into question. Although detection and reporting are related actions (reporting is predicated upon detection), they are in fact distinct and complex processes [6]. Whereas reporting involves an affirmative decision (based on some calculation) to disclose information to another entity, detection involves red flags or risk factors associated with elder abuse that must reach a certain threshold to be noticed. Detection criteria and thresholds for concluding abuse occurred differs across individuals [7,8] contributing to differences among individuals in what they perceive constitutes abuse [9,10]. Whether one subsequently places an official report is impacted by several considerations [11,12], one of which is whether they are mandated to do so (i.e., members of various groups mandated by state law to submit a report if they “suspect” elder abuse).

Compared to the United States, the mandatory reporting policy in other countries is considerably more varied and generally less prevalent (WHO, 2002). In the United States, however, mandatory reporting is sacrosanct in the arsenal against elder abuse. Mandatory reporting laws were initially predicated on the belief that older vulnerable adults are unlikely to self-report abuse to designated authorities such as adult protective services (APS) for a variety of reasons [13]. Therefore, society enlisted the assistance of those who encounter older adults to report its occurrence [14]. With the exception of New York state, all states and the District of Columbia have elder abuse mandatory reporting laws, although the specific provisions vary from state to state [15].Certain groups, such as licensed health care providers, however, are universally designated as mandated reporters. Although it has been widely adopted in the United States, mandatory reporting remains a controversial policy [16,17].

In practice, however, a significant proportion of reports to APS come from non-mandated (i.e., voluntary) reporters [18,19]. A national survey of APS determined that the most common source of such reports is from non-mandated reporters such as family members (17.0%), friends and neighbors (8.0%), and the victims themselves (6.3%), and mandated reporters such as social services workers (10.6%) [18]. More recently, Lachs and Berman (2011) [20] found that among non-mandatory reporters, victims self-report in 17.6% of the cases and family members provided another 14.0% of these reports, while law enforcement personnel (mandated) most frequently reported to APS (22.1%).

These APS reporting statistics would seem to support the widespread belief that older victims of elder abuse eschew reporting. APS reporting data strongly indicate that fewer older victims compared to other groups make official reports to APS. However, it has been suggested that older victims may disclose to informal sources of support such as family and friends [21-23], who may in turn place a report with APS. This suggests that reliance on APS data to support the assertion that older adults eschew reporting may not adequately reflect older adults’ involvement in bringing their situation to the attention of authorities.

To test this hypothesis, we reviewed a convenience sample consisting of 71 official APS cases to determine the role played by older adults in the eventual report to APS. That is, we predict that at least some older adults will disclose an abusive situation to a family member or a friend who in turn places a report to APS.

The participants in this study were a convenience sample of 71 APS caseworkers who had each investigated and responded to a substantiated report of elder abuse, 55 older victims of abuse who had been the focus of one of these reports, and 35 third-party adults who were familiar with the situation, but who had not been an abuser.

The older victims participating in this study were on average 76 years of age (range: 60-94 years), typically female (74%), and generally Caucasian (81%), with 56% not having graduated from high school, 53% a widow(er), and 23% diagnosed with dementia. The APS caseworkers were on average 43 years of age (range: 22-70 years) and had worked 9 years as an APS caseworker (range: 3 months-32 years). Most of the caseworkers were female (92%), 54% held a college degree, and 42% had a masters’ degree. The third-party adults were on average 55 years of age (range: 28-72 years), about half were female (44%), most were relatives of the victim (64%, with the remainder filling such roles as conservator, guardian, psychiatric nurse, and professional caretaker), and had known the older person for a mean of 43 years (range: 1-72 years).

Of the 71 cases of substantiated elder maltreatment studied, 38 were solely financial exploitation cases, 8 were physical abuse cases, 9 were caregiver neglect cases, and 16 were hybrid financial exploitation cases (i.e., financial exploitation co-occurring with either physical abuse (N=6), caregiver neglect (N=9), or both physical abuse and caregiver neglect (N=1)). Categorization of abuse type was based on the APS caseworker’s disposition of the case.

Derived from a review of the literature, a semi-structured interview consisting of six sections was developed specifically for a larger study from which data for the present study were drawn. The person interviewed was initially asked to provide a narrative of what had happened (i.e., Tell me what happened), which was followed by a prepared set of questions probing the characteristics of the abuse, risk factors associated with the older victim, risk factors linked to the abusive individual, the APS and criminal justice system responses, and case outcomes. Twelve iterations of the interview instrument were created for the 4 types of abuse x the 3 groups of respondents. Responses were written on the interview form and transcribed within two days of the interview. Data reported in the current study are drawn largely from the narrative section of the interview. Coding and analysis are described below.

Approval to conduct the study was first obtained from the Director of the Department of Social Services (DSS) of the state in which this research was conducted and then from the APS supervisor responsible for a given jurisdiction. The state in which this study was conducted is divided into a series of distinct APS jurisdictions. All APS supervisors within this state were invited to participate, with 31% of them accepting this invitation. The participating APS supervisors, in turn, invited caseworkers within their jurisdiction to volunteer to participate in this study. No compensation was provided to participating caseworkers as a state law prohibited them from receiving compensation for their participation in research studies. Caseworkers who agreed to participate were asked to identify a recent case that met the following criteria: (1) the case involved financial exploitation, physical abuse, caregiver neglect, or hybrid financial exploitation; (2) the older victim was over the age of 59 at the time of the incident (the prerequisite for a finding of elder abuse in this state); (3) the victim had been living in a domestic setting at the time of the incident, although the victim could be living in an institutional setting at the time of the interview; and (4) the caseworker had issued a final disposition for the case (i.e., that abuse had been previously determined to have occurred, thereby not infringing on an active investigation), although the victim could still be receiving APS services at the time of the interview.

To ensure the privacy of the older victims of abuse, research staff was not permitted to directly invite victims of elder abuse to participate in the study. Rather, the participating APS caseworkers initially contacted older victims to whom they had provided services and asked them if they would be amenable to being interviewed by a researcher from a university as part of a research project seeking to learn more about elder abuse. If the older victim agreed to be contacted, the APS caseworker called the research staff to provide them with the older victim’s contact information and to also schedule his or her own interview. The research staff then called the older person within two days, explained the project in more detail, and, if the older person agreed, scheduled an in-person interview. The two authors of this article jointly conducted the first three interviews to enhance consistency during the interview process, with all remaining interviews conducted by one of the two authors.

Interviews with APS caseworkers took place via telephone. An informed consent form was faxed to the caseworker and returned signed via fax to the researcher prior to the interview. Caseworker interviews lasted on average 71 minutes (range: 30-180 minutes) and their length did not differ statistically with the type of maltreatment discussed. In two-thirds (68%) of the cases, the APS caseworker was interviewed prior to the older victim being interviewed, an occurrence that simply reflected who was first available for an interview.

Interviews with the older victims generally took place in their home, except for three interviews that took place at a local DSS office at the request of the victim. Interviews with the older victims began with a reading and signing of the consent form. A payment of $75 as a gratuity was then given to the older persons, with the researcher emphasizing that the payment was theirs even if they decided later to withdraw from the interview. Interviews with the older adults lasted on average 99 minutes (range: 10-180 minutes) and did not vary significantly with the type of maltreatment explored. There was also no statistical difference by type of abuse in the average length of time that had transpired between the close of the case and the research interview (financial exploitation: 11 months, physical abuse: 5 months, caregiver neglect: 7 months, and hybrid financial exploitation: 13 months).

Interviews with the third-party adults took place either in their home, office, or via telephone. These interviews were always conducted separately from the interview with the older victim. The procedures employed were like those described above for the older victims, including paying a gratuity of $75. The interviews lasted on average 92 minutes (range: 45-180 minutes) and did not differ significantly in length by type of abuse.

The research protocol was approved by the Institutional Review Boards of the university with which the researchers are affiliated (#2005-0258-00) and the Department of Social Services of the state in which the interviews were conducted. Notes capturing the participants’ responses were recorded contemporaneously by the researchers on the survey instrument described above and transcribed in full at the earliest opportunity. (see Jackson and Hafemeister, 2010, for a full description of the methodology) [24].

Up to three narratives (i.e., the APS caseworker, the abused older adult, and the third-party informant) were obtained for each case (described under Semi-Structured Interview) and triangulated to create one coherent account. In 46% of the cases we were able to interview the caseworker and the older adult but not a third-party informant and in 30% of the cases we were able to obtain an interview with all three of these parties. If a discrepancy existed among the three narratives, the victim’s account was given greater weight.

A detector was defined as the person who identified the possibility of elder abuse and set in motion the action or process that would eventually lead to a report, whereas the reporter was defined as the person who placed the official report with APS. The method for determining who detected and who reported the abuse was to read each triangulated narrative and assign a code to (1) the detector and a code to (2) the reporter. The code could be one of 10 categories (see Table 1): APS, medical, law enforcement, professional caretaker, other mandated reporter, older victim, family, neighbor/friend, financial institution, other non-mandatory. For reporters only, the 10 categories were then dichotomized into (1) mandatory (i.e., APS, medical, law enforcement, professional caretaker, other mandated reporter) and (2) non-mandatory (i.e., older victim, family, neighbor/friend, financial institution, other non-mandatory). Chi-square analyses were used to analyze the data.

In 39.5% of the cases, it was the older victim who initially detected the abuse and set in motion events that would lead to an APS report (see Table 1). For example, an older adult may have been unaware that he or she was being financially exploited, but at some point, learned of this abuse and disclosed this information (either to APS or another person). In the remaining cases (60.5%), the older adult was aware of the abuse (e.g., ongoing physical abuse), but events were set in motion towards reporting only after it was detected by someone else, either a mandated (19.7% of the cases) or a non-mandated reporter (40.8% of the cases) (e.g., a family member, a neighbor, or an employee of a financial institution-in the state where this study was conducted, such employees are not mandated reporters). Chi-square analysis revealed no statistically significant association between who detected the abuse and type of abuse.

As shown in Table 1, 40.9% of the elder abuse reports examined in this study were submitted to APS by a mandatory reporter and 59.2% originated from a non-mandatory reporter. Chi-square analysis revealed that the percentage of mandatory versus non-mandatory reporters did not vary significantly with the type of abuse involved (mandatory reporters provided 37% of the reports of “pure” financial exploitation, 50% of the reports of physical abuse, 44% of the reports of caregiver neglect, and 38% of the reports of hybrid financial exploitation), nor by the nature of the relationship between the older adult and the abusive individual (mandatory reporters provided 42% of the reports where the abusive individual was a relative and 39% of the reports where the abusive individual was a nonrelative).

Chi-square analysis, however, revealed several significant differences in reporter by type of abuse (X2 (24) = 41.02, p < .02). APS caseworkers were less likely than expected to report financial exploitation, and more likely to report caregiver neglect. Medical personnel were less likely to report financial exploitation, although more likely to report hybrid financial exploitation. Law enforcement officers were more likely to report physical abuse. And finally, family members were less likely to report caregiver neglect.

As hypothesized, the detector was not always the reporter. However, in 69.0% of the cases (49/71), the detector was also the reporter.

Asnoted above, 39.5% (n=28) of the older victims were the detectors, but in only 18.3% (n=13) of the cases was the older victim both the detector and the reporter. In the remaining cases, the older victim disclosed the abuse to someone who in turn reported it to APS: in some cases the older adult called the police to report the abuse (n=3), while in other instances the older adult told a friend or family member about the abuse (n=5), told someone at another state agency (n=4), or told someone from whom they received services such as a professional care provider or a mental health caseworker (n=2), who in turn reported the abuse to APS.

This paper revealed that at least some older adults play a much larger role in bringing their abusive situation to the attention of APS than official reporting statistics indicate (see also Brank et al. 2011) [21]. Reliance on official statistics would indicate that 18.3% of older adults reported their abusive situation to APS. However, in-person interviews with older victims revealed that an additional 20% disclosed their abusive situation to someone other than APS (e.g., the police, a family member), who ultimately submitted a report to APS. Thus, simply reviewing APS (administrative) data to determine “who reports” abuse masks the active involvement of many older victims attempting to stop the abuse by disclosing their abusive situation to someone in their social milieu [22,23]. This suggests that creating or maintaining a supportive network for older adults is vital to ensuring that they have someone to whom they can disclose.

Voluntary reporters make up a significant proportion of reports to APS. Although efforts to ensure mandated reporters are armed with the tools they need to report (e.g., professional training), targeting similar efforts at voluntary reporters remains a critical gap. For example, ensuring older adults’ social network is aware of how and where to report and get help. Communities can raise awareness about elder abuse by conducting public awareness campaigns, with existing toolkits available to facilitate these efforts [25]. These campaigns also have the added benefit of enlightening society’s attitudes regarding elder abuse, including its harmful effects [26,27]. In addition, gateway programs are being developed in communities to increase the public’s ability to detect and report elder abuse [28]. Such programs, for example, can teach public sector workers (e.g., mail carriers, meter readers), many of whom are well-positioned to observe isolated older adults, how to identify the signs of different forms of elder abuse (i.e., detection) and how to report concerns.

Cohen et al. [6] assert that detection and reporting are two distinct, but related, actions. Thus, someone might detect an abusive situation, but the decision making involved in reporting may dissuade some individuals from reporting. However, our efforts to combat elder abuse have often implicitly assumed that the person who detects abuse is the person who reports abuse. Recognizing the distinction between detection and reporting suggests the need to the tailor our public and professional awareness campaigns distinctly at detection, such as recognizing the red flags or risk factors, and at reporting, such as disseminating information on where to report and what information will be required. Given the differences found among reporters by type of abuse, there may be a need for tailored outreach.

Several limitations associated with study are of note. The study relied on a small convenience sample and therefore warrants replication. It may be that older adults who were invited and agreed to participate in the study have more self-efficacy than those who did not participate and therefore this study may overestimate the self-efficacy of elder abuse victims. However, this study has the unique advantage of reflecting the voices of older adults and thereby revealing their strength that is often disguised. Although this study cannot determine the extent to which APS clients possess this self-efficacy, this study reveals that at last a segment of APS clients are under-represented in the “self-reporting” category of official APS data. Social workers are encouraged to capitalize on their client’s strengths where they exist.

Although older victims are sometimes portrayed as passive, interviews with older adults reveals that many older adults play an active role in attempts to protect themselves from an abusive situation by disclosing to a trusted other, underscoring the importance of capturing victim’s voices in elder abuse research in addition to administrative data. This study also confirmed that the person who detects abuse (becomes aware of and sets in motion eventual reporting) is not always the person who reports abuse, indicating that public awareness efforts may need to be tailored differently for detection and reporting, and separately for voluntary and mandated reporters. Post-hoc results further suggest the need to tailor outreach for specific groups with messages customized for each type of abuse. Although this study awaits replication using a nationally representative sample, the findings suggest that encouraging the detection and reporting of elder abuse by a range of individuals, including encouraging older adults to disclose their abuse to someone in their milieu, have the potential to bring these cases to the public’s attention to ensure that necessary services are offered.