Zero Tolerance Initiative > Common Signs and Symptoms

• Bruises (old and new, clustered on one part of body, or on both upper arms)
• Burns
• Cuts or scars
• Marks left by a gag (or some form of restraint)
• Imprint injuries (eg., marks shaped like fingers, thumbs, hands, belts or sticks)
• Missing teeth
• Spotty balding (from pulled hair)
• Eye injuries (black eyes or detached retinas)
• Broken bones
• Sprains
• Abrasions or scrapes
• Vaginal or rectal pain
• Bleeding from the ears, nose or mouth
• Frequent urinary tract infections or yeast infections
• Painful urination
• Abrasions, bleeding, or bruising in the genital area
• Incontinence in someone who was previously toilet-trained
• Frequent sore throats
• Sudden onset of psychosomatic complaints (males most frequently complain of stomach aches while females most frequently report headaches)
• Sudden difficulty walking or sitting²

• Dehydration
• Poor or improper hygiene
• Poor grooming (e.g., overgrown fingernails and toenails; uncut, matted, or unclean hair; unshaven facial hair, body crevices caked with dirt)
• Malnourishment/weight loss
• A smell of urine or feces on the person
• Clutter, filth, or bad smell in the home
• Improper sleeping, cooking, or bathing arrangements
• Infestations (e.g., fleas, lice, roaches, rodents)
• Poor skin condition or skin breakdown (such as rashes, bedsores, or open wounds)
• Lack of necessary adaptive aids such as glasses, hearing aids, leg braces walkers etc. or improper medication management
• Needed medical and dental care (including the administration of prescribed drugs) not provided
• Lack of adequate or appropriate supervision³

• CHANGES in the way affection is shown, especially if unusual or inappropriate
• Suddenly fears being touched
• Sudden onset of nightmares
• CHANGES in sleep patterns; difficulty sleeping
• Sudden regression to childlike behaviors (i.e., bed-wetting, thumb-sucking)
• Sudden unusual interest in or knowledge of sexual matters (including excessive masturbation)
• Cruelty to animals
• Sudden fear of bathing or toileting
• Sudden fear of a person or place
• Depression, withdrawal, or mood swings
• ANY UNEXPLAINED CHANGE IN BEHAVIOR
  

As you interact with caregivers, you should always be on the lookout for certain behaviors that may be indicators that this person is an abuser. Caregiver behaviors to look for include:

• Refusal to follow directions or complete necessary personal tasks
• Displaying controlling attitudes and behaviors
• Showing up late or not at all
• Working under the influence of alcohol or illegal drugs
• Abusing or harming pets or service animals
• Using threats or menacing looks/body language as a form of intimidation
• Impulsive
• Using vehicle, money or other resources without consent
• Socially isolating person with a disability (including limiting educational and/or employment opportunities)
• Devalues the person with developmental disabilities
• Frequently switches health care providers
• Speaks for the person with developmental disabilities
• Competes with the person with developmental disabilities
• Displays unwelcoming or uncooperative attitude during home visits
• Frequently makes attempts to be alone with a particular individual for no apparent legitimate purpose

Caregivers who abuse, neglect, or exploit people with developmental disabilities are either UNABLE or UNWILLING to provide care to these individuals in an appropriate way.  It is very important to understand what is going on with these types of caregivers because that will help us develop and implement prevention strategies (which we will talk about later on in this training).

Caregivers who UNABLE to provide care appropriately may include individuals who are not properly trained or have the necessary experience to perform their caregiving duties.   They may have mental retardation or mental illness themselves.  Perhaps they are physically unable to provide care to a person with the developmental disability due to their own medical or health condition.  Caregivers who are UNABLE to provide appropriate care may also be overly stressed or overly tired. They may also be working under the influence of drugs or alcohol which limits their abilities.

Caregivers who are UNWILLING to provide care appropriately are more likely to know what they are doing is wrong yet continue to act in that way.  Research shows that these individuals will abuse, neglect, or exploit individuals with developmental disabilities over and over again as long as they are given the opportunity to do so.  Some of these caregivers may not view their victims as actual people (with feelings and emotions).  In other cases, caregivers who are UNWILLING to provide appropriate care see people with developmental disabilities as the perfect victims  who may not be able to defend themselves or tell anyone what has happened.

• Low self-esteem
• Need to control others
• Frustration with authority, which can lead to displaced aggression toward weaker persons
• History of being abused or neglected as a child
• Lack of attachment to the person with the developmental disability ( which can lead to thoughts by the abuser that the person with the developmental disability is not fully human and therefore doesn’t feel or hurt in response to their abusive actions)

Emotional abuse is the most difficult form of abuse to identify. Even though emotional abuse often happens along with other forms of abuse, it can also occur by itself.

Caregivers who have power and influence over others' lives can use that power to harm or exploit, rather than to support and nurture. This can be especially devastating for children in their developmental years, but it can be harmful for anyone.

Emotional abuse can take the form of threats, insults harassment, and less noticeable forms that are difficult to detect. These can be perpetrated by individuals or by representatives of caregiving systems. Here are some of the most common types of emotional abuse and neglect:

• Exposure to domestic violence
• Insults and harassment
• Denial of conditions necessary for physical and emotional well-being
• Denial of communication
• Denial of right to family life
• Denial of social interaction and inclusion
• Denial of economic stability
• Denial of rights, necessities, privileges, and opportunities
• Denial of ordinary freedoms
  

Sometimes abuse of persons with developmental disabilities takes the form of acts that could be thought of as well-intentioned but unsuccessful attempts by the caregiver to ensure the person's well-being.

In other cases, the abuse is deliberate, and is disguised as caregiving. Here are a few examples of that type of abuse:

• Rough physical handling
• Sudden movements of bedding
• Pushing and pulling
• Over-medication
• Unnecessary or excessive use of restraints
• Ignoring dietary restrictions
• Toileting abuse (leaving someone on the toilet too long or not taking them to the bathroom when they need to use it)
• Bathing in water that is too hot or too cold

Using frightening physical actions that stop short of causing serious physical harm is another form of physical abuse that is too often used by abusive caregivers of people with developmental disabilities. Consider how these actions might affect a person with developmental disabilities:

• Grabbing persons with visual impairments from behind
• Jumping in front of persons with visual impairments, or trying to trip them
• Abruptly moving persons with mobility impairments
• Forcing persons with physical disabilities to move from one position to another when they are exhausted or in pain

Bruises are among the most common injuries found in children and adults with developmental disabilities who have been abused.

It is important to remember that occasional bruising is also common in people who are not abused, and that people with some disabilities may be prone to bruising for other reasons. Here are some of the more common bruises that may indicate signs of abuse:

• Facial
• Frequent, unexplained, or inadequately explained
• In unlikely places
• In various stages of healing
• On several different surface areas
• Patterned, reflecting shapes
• Bilateral: means bruises on same places on both sides of the body.  Bruises would appear on both upper arms, for example, may indicate where the abuser applied pressure while forcefully shaking the person.  Bruises on both sides of the body rarely result from accidental causes.
• Regularly evident after an absence, home visit, or vacation

The following are some other physical indicators of abuse or neglect of persons with developmental disabilities. In each case, other indicators such as behavior and circumstances must be considered.

Questionable cuts and scrapes

Consider:
• Frequent, repetitive, unexplained, or inadequately explained scrapes
• Atypical locations such as mouth, lips, gums, eyes, external genitalia (e.g., places other than palms, knees, or other areas usually covered by clothing)
• Patterned scarring that may be due to inflicted injuries such as whipping

Burns or scalds

Consider:
• Patterned burns(e.g., shaped like a cigarette butt or electrical appliance)
• Burns in specific locations such as several burns on different parts of the body or on particularly sensitive locations, such as soles, palms, back, or buttocks
• Immersion burns, which appear sock-like, glove-like, or doughnut-shaped on buttocks, genitalia, or limbs

Bites

Consider:
• Human bite marks are easily distinguished from those of animals by their size and shape, and whether flesh is torn.
• If bites are explained as self-inflicted, the location and position of the bite must be consistent with the person's functional abilities.

Ligature marks and welts (which could have come from being tied up or gagged)

• Could be the result of whipping
• Welts often follow clearly defined stroke patterns, especially if the person was immobile during the whipping
• Chafing and bruising, sometimes accompanied by swelling, on the wrists, ankles, throat, or penis can be the result of being tied up or choked
• Even when choking is severe or fatal, bruising may be faint or entirely absent

Eye and ear injuries

• Sudden or unexplained hearing loss
• Cauliflower ears (i.e., thickened external ear structures)
• Bruising to the outer ears
• Blood behind the eardrum
• Retina hemorrhage or other intraocular bleeding

Dental and mouth injuries

• Lost or broken teeth, particularly if unrelated to dental disease, normal loss of children's teeth, or accidental causes
• Repeated, unexplained, or inadequately explained dental injuries
• Facial bone or jaw fractures
• Bruising of cheeks and gums at corners of mouth (from gags)
• Cuts or bruises on the tongue
• Discoloration of the teeth as a result of previous abuse

Dislocations of joints

• Repeated dislocations of joints in the absence of a known disease process may indicate shaking, twisting, or pulling
• Frequent or multiple dislocations in the absence of a clear explanation may indicate physical abuse

Fractures:

• Repeated or multiple fractures in the absence of a known disease process or clear explanation may indicate abuse
• Old, untreated fractures can indicate chronic abuse
• Spiral fractures that result from twisting limbs may be related to abuse in non-ambulatory children and adults with developmental disabilities

Coma:

• Shaking and other forms of abuse can result in coma of undetermined origin without external injuries. Comas not associated with known accidental causes or clearly identified disease processes should also be suspected.

Accidents happen with everyone, including people with developmental disabilities. The following is a guide to help you tell the difference between accidental and non-accidental injuries. When observing an injury that might be the result of abuse, consider these factors:

Location of the injury:

• Certain locations on the body are more likely to sustain accidental injury. These include the knees, elbows, shins, and forehead.
• Protected body parts and soft tissue areas, such as the back, thighs, genital area, buttocks, back of legs, or face, are less likely to accidentally come into contact with objects that could cause injury.

Number and frequency of injuries:

• The greater the number of injuries, the greater the cause for concern. Unless the person is involved in a serious automobile accident, he/she is not likely to sustain a number of different injuries accidentally. Multiple injuries in different stages of healing are also a strong indicator of chronic abuse.

Size and shape of the injury:

• Many non-accidental injuries are inflicted with familiar objects: a stick, a board, a belt, a hair brush. The marks which result bear a strong resemblance to the objects used. Accidental marks resulting from bumps and falls usually have no defined shape.

Description of how the injury occurred:

• If an injury is accidental, there should be a reasonable explanation of how it happened that is consistent with the appearance of the injury. When the description of how the injury occurred and the appearance of the injury are inconsistent, there is cause for concern. For example, it is not likely that a person's fall from a wheelchair onto a rug would produce bruises all over the body.

Consistency of injury with the person's developmental capability:

• As children grow and gain new skills, their ability to engage in activities that can cause injury increases. A toddler trying to run is likely to suffer bruised knees and a bump on the head. Toddlers are less likely to suffer a broken arm than an eight-year-old who has discovered the joy of climbing trees.

Behavioral signs can be extremely important in detecting abuse and neglect, especially in people who have communication challenges and are unable to tell anyone about what happened to them. In many cases, physical signs of abuse may not yet be present or noticed so behavioral signs are often the first indicators. Usually it is a combination of physical and behavioral changes that are seen in people that have been abused.  Here are some of the behavioral signs of possible abuse:

Aggressive behavior

• Is widespread among victims of abuse
• May imitate the aggression committed against the abused person (e.g., the child who is whipped may whip smaller children)
• May generalize to other forms of aggression, such as yelling or hitting others
• May be exhibited through excessively violent drawings, stories, or play

Atypical attachment
Consider:

• Children who have been abused often appear insecure with strangers, and compulsively seek the presence and attention of their primary caregivers, yet may express little affection towards them
• A preschooler may cling to his mother and cry excessively both when she leaves him and when she returns
• The person who has been abused may be uncomfortable with physical contact with anyone

Disclosure

• Direct disclosures of abuse, neglect, or exploitation are powerful evidence, even when some details are incorrect.
• Complaining of soreness or pain when unrelated to disability or illness.
• All disclosures should be given attention and referred to the appropriate authorities for full evaluation.

Fearfulness
Victims of abuse often appear fearful of others:

• Fear can be specific to the abuser, but may generalize to other people or places
• Fear may be age or gender-specific (e.g., the child who turns away and raises his or her arms as if to ward off a blow whenever an adult nearby makes a sudden move)
• The person may be afraid to go home, or afraid to leave home
• The child may be afraid to change clothes for gym activities (may be attempting to hide injuries, bruises), or may be afraid to take off a long-sleeved shirt even in the heat

Learning Disabilities

Difficulty learning can be a result of abuse for complex reasons. Much of the child's energy is directed toward surviving the abuse and coping with stress. This leaves little energy for learning or other typical childhood activities.

Psychotherapy, or other appropriate treatments, can lead to improvement for those whose learning disabilities resulted from their psychological response to abuse.

Noncompliance
People who are abused often become noncompliant. Noncompliance:

• May be a generalized response to frustration, or an effort to gain personal control
• May be aimed at avoidance of the abuser or the abusive situation
• Can take the form of chronically running away (adolescents)

Regression
Often children who are abused behave like younger children. This form of regression:

• May reflect their inability to move through normal stages of development in the face of intense anxiety
• Could reflect a mechanism of escape
• Can be limited to affective and interpersonal behavior
• Can extend to developmental skills such as toileting (e.g., a child who was previously toilet trained may begin to have accidents after experiencing abuse)

Sleepdisturbance

• Having nightmares or trouble getting to sleep are characteristic of abused persons
• This can lead to further abuse due to caregiver frustration and loss of sleep

Withdrawal

• People who are abused often withdraw from others and spend much of their time alone
• Sometimes the withdrawal is related to depression
• Sometimes the person will alternate between withdrawal and aggression
• Aggression may be the person's way of discouraging interaction with others. For example, an abused child may keep to himself and avoid other children, but become aggressive when unable to avoid interaction⁴.

Taking advantage of individuals with a developmental disability can rob them of their independence and the ability to afford the basic necessities of life, such as food, rent payments and medicine. It's also a crime and should be reported right away to the Florida Abuse Hotline.

In particular, financial exploitation often goes unreported or is reported long after the damage is done. When that happens, the suspect is far more likely to get away with the crime and move on to other victims. Here are a few signs to watch for:

• Sudden decrease in bank account balances
• Sudden change in banking practices (such as making several large withdrawals from a bank account or ATM over a period of several days instead of one small withdrawal each week)
• Sudden problems paying bills or buying food or other necessities
• Sudden changes in wills or other financial documents
• The person begins to act very secretively. (Telephone con artists often try to isolate their victims to avoid detection by telling the victim not to let anybody know about their calls.)
• Unexplained disappearance of money or valuable possessions
• Substandard care being provided or bills which are late or unpaid despite the availability of adequate financial resources
• Concerns expressed by a person with a developmental disability that he or she is being exploited
• Lack of money early in the month (when disability or other types of government benefits are paid)

If you notice any of these signs or suspect that a person with a developmental disability might be a victim of exploitation, please contact the Florida Abuse Hotline immediately.

A number of factors can make it difficult to identify abuse, neglect, and exploitation of persons with developmental disabilities.

Person does not recognize abuse, neglect, or exploitation. In order to let someone know they are being maltreated, victims of abuse must:

• Recognize the behavior as abusive
• Consider it significant enough to report
• Be able to communicate to someone about the abuse
• Be believed

"I wasn't able to say, "knock it off" to my family who was doing my personal care. I thought it was normal to be tossed around in my chair. To have a comb dragged through my hair so it comes out. To be left on a toilet for an hour. It took me about five years of hiring people, when I realized that I didn't have to accept those things."⁵

Many people with developmental disabilities have grown accustomed to being treated without respect, and are used to routine treatment that most other people would not tolerate. People with developmental disabilities may view only the most severe acts against them to be worthy of attention and possible reporting. The victim may consider an incident "unimportant" unless it involves serious physical harm.

Greater personal assistance needs
Some people with physical disabilities require help with personal care routines such as dressing and bathing throughout their lives. Personal care routines require physical contact, and may result in occasional touching of sexual parts of the body, with the result that the person can't tell whether these touches are accidental, required, or abusive.

Fear of not having needs met
People with developmental disabilities who are dependent on others for their day-to-day care may be fearful that if they let anyone know they are being mistreated, they will no longer receive the care they need. They may also fear reprisals from their caregivers if they tell anyone.

Communication challenges
Some people with developmental disabilities are limited in their ability to communicate verbally about an abusive incident. Adaptations may be required to insure adequate communications. Behavioral and circumstantial indicators become more important in identifying abuse, neglect, and exploitation in these cases.

Self-abusive behaviors
Some people with developmental disabilities resulting in behavioral or cognitive impairments engage in self-abusive behaviors, or are prone to accidental injury. This makes it more difficult to identify abuse, neglect, or exploitation when it occurs for these persons.

Signs of abuse may be interpreted as behavioral problems
The best rule of thumb for recognizing the behavioral signs of abuse, neglect, or exploitation is to know what is normal behavior for the particular person. When assessing the person's behavior, it is important to take the following steps:

• Examine the history of the behavior
• Obtain a behavioral baseline
• Determine whether there has been a clear behavior change that has taken place during the time frame in question
• Consider any changes in the intensity and duration of the behavioral episodes

"If they're (personal assistants are) feeling angry for some reason…at you or whatever, they might set you down in your chair a little harder than normal. Or…position you in a little rougher way. And you sit there thinking, 'Now did he mean to do that?' It's really hard to distinguish. It makes you question yourself a lot."⁶

While some actions (such as punching) are easy to identify as abuse, other forms of mistreatment by caregivers are harder to spot (although they still represent acts of abuse). Below are examples of what can be termed "subtle" abuse:

• Ignoring a person when they ask for help
• Making a person beg for help
• Providing help in a way that makes the person feel like a burden or feel guilty
• Intentionally making a person wait for help
• Refusing to recharge the battery of a person's wheelchair
• Providing physical care in a way that is unnecessarily rough or careless
• Refusing to provide help unless the person agrees to lend money
• Purposely unplugging or turning off adaptive equipment⁷

There are a number of conditions that may lead you to incorrectly think that someone with a developmental disability has been abused or neglected. Here are some of the most common:

Directions:
For each scenario below, choose the best answer from the selections below. (Answers appear at the end of this activity).

• Physical Abuse
• Sexual Abuse
• Sexual Misconduct
• Neglect
• Exploitation
• None of the above

1. You are a waiver support coordinator who has a 27-year-old client named Lila, who lives in her own apartment. Lila has cerebral palsy and has a personal care assistant (PCA) come into her apartment every morning to help her get out of bed, bathe, and get dressed. She is able to transfer from her wheelchair to the toilet but requires some assistance from the PCA to ensure she doesn't fall. She recently hired a new PCA who she really likes. On a recent home visit, you noticed a large bruise on Lila's arm. When you asked Lila about it, she said that she was falling during a transfer and her PCA grabbed her arm to catch and steady her. When you asked the PCA about the bruise, she reported the same thing.

What might you suspect?

2. Carey is a 25-year-old man who lives in a group home. He has autism and mild mental retardation. He is extremely sensitive to touch, and he occasionally scratches and hits himself when he gets frustrated with the way certain clothes or seats feel as they touch his skin. During a recent visit home, his father noticed bruises on both of his upper arms. He asked Carey about them and Carey said that it was a secret. Carey's dad asked him who else knew the secret, and Carey answered "Drew", one of the staff members at his Adult Day Training (ADT) program.

What might you suspect?

3. You work at a group home where Maria has been a resident for several years. Maria is an engaging young woman who is always smiling and enjoys social interaction with both the other residents of the home as well as the group home staff. Maria is non-verbal and will often indicate her needs and choices by pointing or shaking her head (in response to simple yes/no questions). Recently you have been noticing a sudden change in Maria's behavior when you try to help her with her shower. She appears terrified to go into the bathroom and cries and shakes her head whenever staff try to lead her in that direction. You also notice that she has been coming home from school with wet clothes in her backpack (when she previously had no problems using the bathroom)

What might you suspect?

4. You are a provider of Companion Services for Jacob, who is a 29-year-old man with moderate mental retardation who lives in an apartment with one roommate. Jacob also receives In Home Support Services from a provider who comes in once a week to help him pay his bills and balance his checkbook. As Jacob's companion provider, you usually take him to the library and then stop for a soda on the way home. One afternoon, Jacob says he can't buy a soda because he doesn't have the money. Upon further questioning, you learn that he doesn't have the money because his in-home support services provider has been taking money from him (which the provider says he needs to pay for his bus fare to Jacob's apartment).

What might you suspect?

5. Your sister Jennifer is a 27-year-old legally competent woman who lives in a group home. Jennifer tells you that one of the newly-hired group home staff members is her boyfriend and that they sometimes kiss each other on the mouth. She is very happy and says that the two of them are in love.

What might you suspect?

6. You work at an Adult Day Training (ADT) program and notice that Joseph, a 39-year-old man who uses a wheelchair, usually arrives at the ADT in dirty clothes and is wearing a diaper that looks like it hasn't been changed since the night before. Over the past several weeks, it looks like Joseph appears to be losing weight. When you took him into the bathroom to change his diaper, you notice that he has a number of large pressure sores on his buttocks.

What might you suspect?

Answers:

1. F. None of the above.If you feel comfortable that Lila's explanation of the bruise was truthful (and that her statements were made while the PCA was not in the room), then it is not likely that she is being abused. However, you should monitor the situation to see if any additional information or evidence of abuse appears.
2. A. Physical Abuse. Bilateral bruises (appearing on both arms) may be an indicator of physical abuse.
3. B. Sexual Abuse. Sudden changes in behavior (such as the fear of a certain room in the home) and incontinence in persons who were previously toilet-trained may be indicators of sexual abuse.
4. E. Exploitation. A caregiver who borrows money from a person with a developmental disability without his or her knowledge, consent, or understanding may be guilty of exploitation.
5. C. Sexual Misconduct. Sexual activity between a group home staff member and a resident of that group home is a crime, regardless of whether or not the resident provided his or her consent.
6. D. Neglect. Pressure sores, weight loss, dirty clothing, and heavily soiled diapers may be indicators of neglect.