Common Signs and Symptoms of Abuse, Neglect, and Exploitation
Perhaps the most difficult aspect of recognizing the signs and symptoms of
abuse and neglect is that individuals with developmental disabilities may exhibit certain physical and/or behavioral traits due to the nature of their disability. Therefore, It is very important to recognize changes in behavior or health (particularly those not typically associated with the individual's disability) as potential abuse indicators. It is also important to note that there is no universal response to abuse or neglect.
Above all else, be mindful that any sudden change in the physical, behavioral, or financial status of someone with a developmental disability may be the result of past or ongoing incidences of abuse, neglect or exploitation.
While each victim of abuse, neglect, or exploitation will respond differently, the available research data reveals that the presence of certain physical and behavioral indicators (described in greater detail below) are highly correlated with abusive situations and environments.
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Physical Indicators of Abuse
- Bruises
- Burns
- Cuts
- Lacerations
- Broken bones
- Sprains
- Abrasions
- 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 sitting
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Physical Indicators of Neglect
- Bedsores
- Dehydration
- Poor or improper hygiene
- Malnourishment
- Lack of necessary adaptive aids or improper medication management
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Behavioral Indicators
- 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
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Behaviors and Characteristics of Abusive or Neglectful Caregivers
If you work with other caregivers, you should always be on the lookout for certain behaviors and characteristics that may be indicators that this person is an abuser. Caregiver behaviors and characteristics 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
- Switches healthcare 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
- Low self-esteem
- Mental illness, diminished intelligence, or impaired functioning
- 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 dependent person, which can lead to depersonalization
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Types of Emotional Abuse and Neglect
Emotional or psychological abuse is the most difficult form of abuse to identify. All abuse produces psychological consequences, which can be the most devastating. But even though emotional abuse often accompanies other forms of abuse, it can also occur independently.
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.
Verbal and emotional abuse can take the form of threats, insults harassment, and more subtle 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 forms 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
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Physical Abuse as a Perversion of Caregiving
Sometimes abuse of persons with developmental disabilities takes the form of acts that could be construed as well-intentioned through unsuccessful attempts by the caregiver to ensure the person's well-being.
In other cases, the abuse is deliberate, and is disguised as caregiving. Consider:
- Rough physical handling by healthcare providers
- Abrupt movements of bedding
- Pushing and pulling
- Over-medication
- Unnecessary or excessive of restraints
- Ignoring dietary restrictions
- Toileting abuse
- Bathing in water too hot or too cold
- Aversive treatments
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Frightening Physical Actions
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
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Physical Signs of Abuse: Questionable Bruises
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 difference 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, visitation, or vacation
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Other Physical Indicators of Abuse
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 abrasions or lacerations
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
- 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 accompanies 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)
- Contusions or lacerations of the tongue
- Discoloration of the teeth as a result of previous abuse
Dislocations of joint injuries
- 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 suspect.
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Distinguishing Abuse from Accidental Injury
Accidents happen with everyone, including people with developmental disabilities. The following is a guide to help distinguish 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 like to suffer a broken arm than an eight-year-old who has discovered the joy of climbing trees.
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Behavioral Signs of Abuse
Behavioral signs can be extremely important in detecting abuse and neglect, especially in people who have communication challenges and are unable to verbally disclose abuse, neglect, or exploitation. In many cases, physical signs of abuse may not yet be present or apparent, and behavioral signs are the first indicators. Usually it is a combination of physical and behavioral abnormalities that can be detected in abused persons with developmental disabilities. Here are some of the behavioral indicators 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
- 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)
Sleep disturbance
- 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 interaction
(Source: Abuse and Neglect of Children and Adults with Developmental Disabilities: A Web Course for Health and Other Professionals, Virginia Commonwealth University, 2005.)
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Signs and Symptoms of Exploitation
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 promptly to the Florida Abuse Hotline as well as the police.
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. (Con artists often try to isolate their victims to avoid detection by telling the victim not to let anybody know about the 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
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 and the police immediately.
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Factors That Make it Hard to Recognize Abuse, Neglect, and Exploitation
A number of factors can make it difficult to identify abuse, neglect, and exploitation of persons with developmental disabilities.
An individual's denial, lack of education, social isolation and segregation, fear of reprisal, fear of losing disability-related services, and preoccupation with financial and basic care needs all conspire to overshadow the significance of abuse and neglect when they occur. In addition, symptoms may be confused with a disability, which makes it even more difficult to distinguish possible abuse or neglect from an actual disability.
Consider these other factors:
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
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 exploitive.
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 maltreated, they will no longer receive the care they need. They may also fear reprisals from their caregivers if they tell anyone about the abuse.
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 discerning 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
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Conditions of People with Developmental Disabilities That Can Mimic Abuse
There are a number of conditions that can mimic signs of abuse in persons with developmental disabilities. Healthcare professionals need to be aware that these conditions can be misinterpreted as signs of abuse. Here are some of the most common:
- Injuries due to falls
- Sensory impairments
- Skin breakdown from appliances or orthopedic equipment
- Self-injurious behavior (SIB)
- Poor growth and failure to thrive
- Fractures
- Sensory integration problems: Some people with a variety of disabilities (mental retardation, autism, cerebral palsy, alcohol-related neurodevelopmental disorder, attention deficit hyperactive disorder) may be hypersensitive to touch, textures, taste, or temperature. This may manifest as feeding disorders, with excessive tactile defensiveness and gagging. These persons may resist hugs, face washing or other innocuous types of touch. This can also manifest as failure to thrive or significant behavioral problems.
- Mongolian spots: Mongolian spots are congenital bluish or bruised-appearing areas that are usually seen on the lower back or buttocks. These spots are benign and occur more commonly in persons of color. They may remain for months or years.
(Source: Abuse and Neglect of Children and Adults with Developmental Disabilities: A Web Course for Health and Other Professionals, Virginia Commonwealth University, 2005).
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