In the 1970s a series of major scandals about nursing home quality gave rise to both congressional and state investigations and further focused attention on the protection of the elderly. Legislative changes at the state level ensued. By 1985, 46 states designated a responsible agency for elder protective services. In 1998, the current National Center on Elder Abuse (NCEA) was established.⁸ State agencies and national professional organizations have established numerous guidelines and reference sources to assist in the detection, intervention, monitoring, and treatment of both child and elder abuse and neglect. The American Psychiatric Association (APA), American Medical Association (AMA), National Center on Child Abuse and Neglect (NCCAN), National Center on Elder Abuse (NCEA), and state social service agencies are some of the groups that have provided extensive information to address abuse and neglect in these populations. Every state, every United States territory, and the District of Columbia now have laws governing child and elder abuse and neglect. While the minimum standards for defining abuse and neglect are federally mandated, individual states may develop their definitions and standards regarding abuse and neglect, so long as they exceed the federal standard.^6,⁷ For example, in some states, voluntary reporting is permitted for some entities. However, in every state, reporting is mandatory for professional caregivers (including doctors, nurses, therapists, and social workers). Every state has laws that require physicians to report suspected abuse or neglect, and in some states suspicion of abuse or neglect alone, or “reasonable grounds,” is sufficient to trigger the duty to report. It is critical that physicians and other mental health providers familiarize themselves with the specific standards and requirements for mandated reporting in every jurisdiction in which they practice. For example, some physicians and mental health clinicians may feel that reporting a caregiver or a child’s parents might pose difficulties in terms of the therapeutic alliance. These professionals may be tempted to try to work with these families before notifying state social services. It is important to note that doing so can leave mandated reporters vulnerable to legal prosecution for failure to file a timely report and to civil liability for failure to protect a patient from harm by delaying a mandated report.¹⁰ Finally, many state laws grant immunity to physicians who report in good faith, thereby minimizing exposure to liability for reporting abuse and neglect.¹¹

TYPES OF ABUSE AND NEGLECT

Federal and state laws describe various types of abuse and neglect for both children and the elderly. For both groups these subcategories of abuse and neglect include physical abuse, emotional (psychological) abuse, sexual abuse, and neglect. This chapter will focus on physical and emotional abuse and on neglect. The topic of sexual abuse is beyond the scope of this chapter.

CHILD ABUSE AND NEGLECT

Types of Maltreatment

The federal Child Abuse Prevention and Treatment Act (CAPTA) provides minimum standards for the definition of child abuse and neglect. Under CAPTA, which was recently amended by the federal Keeping Children and Families Safe Act of 2003, child abuse and neglect is defined as “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, or an act or failure to act which presents an imminent risk of serious harm.”¹² The federal definition in CAPTA has been the subject of many different interpretations. Specifically, there are many competing approaches to how this legislation should be applied and incorporated into state law. For example, certain states define child abuse and neglect as a single concept whereas others consider abuse and neglect as different entities that require separate definitions. In addition, the standard for what constitutes abuse can also vary among states. Despite these jurisdictional differences, abuse is most often defined by states as “harm or substantial risk of harm” or “serious threat or serious harm” to a child.⁶ For example, the state of Massachusetts defines child abuse as “physical or emotional injury.…which causes harm or substantial risk of harm to the child’s health or welfare including sexual abuse, or from neglect, including malnutrition, or who is determined to be physically dependent upon an addictive drug at birth.”^13,¹⁴ As mentioned previously, each state can determine the grounds for intervention to protect a child, but there are common trends among states. For example, a “child” is generally defined as a person who is under age 18 and not an emancipated minor. Emancipation status is not available in every state, but, in the majority of states in which it is, emancipation is a legal status that allows minors to attain the rights of legal adulthood, provided certain criteria are met, before the age at which they would normally be considered adults. Twenty-eight states provide emancipation status and 22 states do not. (States with some form of emancipation status are Alabama, Alaska, California, Colorado, Connecticut, Florida, Hawaii, Illinois, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Virginia, Washington, West Virginia, and Wyoming.) For example, in some states a child who is married, a parent, or in the armed forces can be considered emancipated.¹⁵ It is important to review the relevant statutes specific to each state of practice to know which criteria apply.

Physical Abuse

Worldwide, definitions of what constitutes physical abuse vary among (1) individual country, state, or jurisdiction; (2) cultural norms; and (3) biological predispositions. When physical abuse is suspected, it is important to consider the cultural and ethnic influences that may validate different interpretations of abuse.^16,¹⁷

In the United States, Dr. C. Henry Kempe’s landmark 1962 publication ¹⁸ coined the term battered child syndrome. Kempe described findings consistent with a pattern of abuse that included the existence of multiple bone fractures in different stages of healing that were suggestive of child maltreatment.¹⁸ Since that time, the types of physical findings linked to nonaccidental injuries have grown dramatically in scope and the methods of detection have become increasingly sophisticated. Even with increased knowledge and diagnostic abilities, one of the most common methods used to screen for the presence of physical abuse remains a discrepancy between the physical findings and the parent’s or caregiver’s explanation of the mechanism of injury.¹⁹ The identification of inconsistencies between the report provided and the objective data on physical examination are important as evidence that the stories given do not reflect reality and that injuries may be sustained as the result of intentional infliction rather than by accidental means.

Emotional Abuse

Mental injury to a child can have pervasive and long-term effects on a child’s development. It is important to recognize that emotional abuse may accompany physical abuse, sexual abuse, or neglect, but may also occur entirely independent of other forms of maltreatment. To date, 48 states include emotional maltreatment within their definition of child abuse.²⁰ (Georgia and Washington do not include emotional abuse in their statutory definitions.) Emotional abuse has been defined by a number of national organizations, including the AMA, the American Academy of Pediatrics, the United States Department of Health and Human Services, and the National Center on Child Abuse and Neglect. According to the American Academy of Pediatrics Committee on Child Abuse and Neglect, emotional abuse is defined as “psychological maltreatment.…[from] a repeated pattern of damaging interactions between parent(s) and child that becomes typical of the relationship.”^20,²¹ In some situations the pattern is chronic and pervasive, whereas in others these damaging interactions occurs only in the setting of specific triggers or “potentiating factors.”²² Overall, emotional maltreatment occurs “when a person conveys to a child that he or she is worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another’s needs. The perpetrator may spurn, terrorize, isolate, ignore, or impair the child’s socialization.”⁶ Psychological maltreatment assaults a child’s emotional, social, and basic human development. Gabarino and others have described forms of psychically destructive behavior inflicted by an adult on a child and the ways these types of emotional abuses may manifest from a developmental perspective.^23,²⁴

Emotional abuse can be manifest in a variety of ways (Table 83-1).²⁵^–²⁸ Although emotional abuse has been studied and characterized, the text revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) does not include a diagnosis for emotional abuse. The DSM-IV-TR instead specifies five “problems” that may arise “related to abuse or neglect”: (1) physical abuse of a child, (2) sexual abuse of a child, (3) neglect of a child, (4) physical abuse of an adult, and (5) sexual abuse of an adult. Another DSM-IV-TR diagnosis that may be encountered when dealing with children who are victims of abuse and neglect is “Reactive Attachment Disorder of Infancy or Early Childhood.” According to the DSM-IV-TR, this is defined as “markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years.…pathogenic care as evidenced by.…persistent disregard of the child’s basic emotional needs.…disregard of the child’s basic physical needs.…and/or repeated changes of primary caregiver that prevent formation of stable attachments.”²⁹ Despite the fact that emotional abuse can lead to long-term harm, it is often difficult to substantiate suspicions or allegations of emotional abuse. Specifically, the damage suffered by the child may not be as apparent as can the outwardly visible signs of physical abuse. Some states therefore require that a psychiatric or psychological diagnosis be linked to the alleged emotional abuse in order to establish a causal connection between the child’s disorder and the wrongful behavior by the parent or the caregiver.

Table 83-1 Manifestations of Emotional Abuse

Corrupting

A form of exploitation that encourages the development of inappropriate behaviors (e.g., aggressive, criminal, sexual, or substance-abusing behaviors)

Degrading

Disdainful rejection, spurning, humiliation, ridicule, or criticism that can include being shamefully singled out in public

Ignoring

Failure to provide emotional responsiveness, or an interest or display of affect toward the child

Inconsistent Parenting

Ambivalent, contradictory, or unreliable behavior toward the child

Isolating

Confining or withholding of interactions with other caregiver or peers, unreasonable limits on social interactions

Rejecting

Avoiding the child, refusing to acknowledge or allow inclusion in activities with family or others

Terrorizing

Intimidating, threatening, or exposing the child to acts that make the child feel unsafe

Witnessing Violence or Cruelty

Exposure to domestic violence or destructive physical behavior by caregivers

Neglect

According to the most recent data report from the National Child Abuse and Neglect Data System (NCANDS), neglect is the most common form of child maltreatment reported to state protective services. More children suffer from neglect than from physical and sexual abuse combined.³⁰ Despite the fact that neglect makes up approximately half of all reported cases of child mistreatment in the United States, it receives less consideration in the literature and the media as compared to physical and sexual abuse. Part of the reason that child neglect receives disproportionately less attention than abuse may be related to difficulties in defining what constitutes neglect. Neglect is generally defined as deprivation of adequate clothing, food, medical attention, or shelter, or a failure to provide other needed age-appropriate care. Although the federal government, through CAPTA, provides minimum standards for child neglect, as in the case of child abuse, states have operationalized the federal standard by implementing definitions that vary widely. That being said, neglect is generally considered as an act of omission rather than one of commission and most definitions incorporate the concept of nonprovision of, or inability to provide, adequate care.^31,³²

Other generalizations may be drawn from state laws about neglect. For example, neglect is typically broken down into five main categories: emotional neglect, physical neglect, medical neglect, failure to thrive (FTT), and educational neglect. Like emotional abuse, neglect is more difficult to identify than is physical abuse because the more easily identified stigmata of scars, marks, or bruises are often not present. In the absence of demonstrable evidence of harm in settings of neglect, it is often difficult for child protective services to intervene since intervention requires such evidence.

Failure to Thrive.

Failure to thrive (FTT) is defined as “a significantly prolonged cessation of appropriate weight gain compared with recognized norms for age and gender after having achieved a stable pattern.”³⁷ Inadequate provisions of nutrition and disturbed social interactions are both considered significant factors that result in the syndrome of FTT. Although FTT can be unintentional or caused by organic disease (e.g., cystic fibrosis, inborn errors of metabolism, or human immunodeficiency virus [HIV] infection), a significant number of cases are the consequence of child neglect. This neglect is often emotional, resulting from parents or caregivers who exhibit socially maladaptive “interactional behavior and less positive affective behavior” that leads to FTT in the child.³⁷ As such, infants, toddlers, and children with FTT are at risk for attachment disturbances. Mental health professionals should be particularly attuned to the parental or caregiver’s response to the child’s needs and general emotional availability when evaluating for FTT.

Educational Neglect.

Generally, states require children to attend school until either a certain age or grade level. If a parent permits chronic truancy or fails to enroll a child in school, this may constitute educational neglect, especially if the caregiver has been informed of the situation but fails to correct the problem. Likewise, if a child has special educational needs and the parent or caregiver fails to follow through with providing necessary treatment or exercising diligence in obtaining educational services, a finding of educational neglect may be warranted. Some states provide avenues for legal enforcement of school attendance by truant children where parents are unable to manage the child.³⁸

Epidemiology

Child maltreatment is a medical and public health problem that affects nearly 12 out of every 1,000 children per year.³¹ In 2004, according to the National Child Abuse and Neglect Data System (NCANDS), approximately 3 million children were alleged to have been abused or neglected. In addition, over 872,000 children were determined to be victims of maltreatment. In the national system that tracks child abuse and neglect, NCANDS, children are counted as victims if an investigation by a state social services agency determines the case to be either “indicated” or “substantiated” maltreatment.³¹ If a case is substantiated, an allegation of risk of harm or actual abuse was founded according to individual state definition. Indicated cases of maltreatment include situations where abuse or neglect could not be substantiated, but there was reason to suspect maltreatment. Children who belong to certain age-groups and ethnic groups are at heightened risk for abuse and neglect. For example, children ages 3 and younger had a reported maltreatment rate of 16.1 per 1,000 compared with 6.1 per 1,000 for 16- to 17-year-olds.³⁹ According to data calculations from another data bank, non-Hispanic black, American Indian, Alaskan Native, and Pacific Islander children have higher rates of maltreatment than children from other ethnic groups. Specifically, in 2004, non-Hispanic black children had a reported maltreatment rate of 19.9 per 1,000 children, Pacific Islander children had a rate of 17.6 per 1,000 children, and American Indian and Alaskan Native children had a reported maltreatment rate of 15.5 per 1,000 children, compared with 10.7 per 1,000 non-Hispanic white children, 10.4 per 1,000 Hispanic children, and 2.9 per 1,000 Asian children.³⁹

Child death is the most significant and devastating outcome of abuse and neglect. However, the prevalence is difficult to quantify. Recent studies in Colorado and North Carolina found that deaths from child abuse and neglect were underestimated in state records by approximately 50% to 60%. This under-recording is due to many factors, including the varying state definitions of “child homicide,” “abuse,” and “neglect,” which can result in child deaths due to maltreatment not being reported on death certificates as deaths resulting from abuse or neglect.⁴⁰^–⁴² Child death due to maltreatment and the problem of under-recording of child deaths due to abuse and neglect occurs in all nations of the world.

In 2003, the United Nations Children’s Fund (UNICEF) published a report on child deaths due to mistreatment in industrialized countries.⁴³ The UNICEF report found that 3,500 children under age 15 die each year from abuse or neglect in 27 wealthy nations. The study also reported that “two children die from abuse and neglect every week in Germany and the United Kingdom, three a week in France, four a week in Japan, and 27 a week in the United States.” Further, “five nations—Belgium, the Czech Republic, New Zealand, Hungary and France—have levels of child maltreatment deaths that are four to six times higher than the average for the leading countries. Three countries—the United States, Mexico, and Portugal—have rates that are between 10 and 15 times higher than the average for the leading countries.”⁴³ While child maltreatment remains a domestic and international problem, United States and international data have both shown a trend toward improvement in some areas. United States data sources show that the rate of victimization per 1,000 children in the United States national population dropped from 12.5 children in 2001 to 11.9 children in 2004.³¹ Internationally, the figures for child deaths due to maltreatment appear to be on the decline in the majority of industrialized nations.⁴³

Risk Factors

No child is immune from abuse, and the circumstances that lead to maltreatment are complex and only partially understood. Child abuse can be inflicted by any person who cares for a child and it can occur in many different types of settings. However, there are certain factors that place some children at higher risk for mistreatment than other children. Studies and case reports have enumerated some criteria associated with abuse and neglect. Some of the most frequently cited risk factors include child morbidity, cultural background, family violence, low socioeconomic status, parental mental or physical illness, parents who themselves were victims of abuse, and social isolation or family breakdown.^20,⁴⁴^–⁴⁶ These risk factors are often grouped into three main categories: child-associated risk factors, family-associated risk factors, and environmental characteristics.

Child-Associated Risk Factors

Many types of child-associated factors can contribute to this category of risk factors. For example, children with certain types of illnesses or deficits may be more difficult to care for and may overwhelm the abilities of caregivers to provide adequate care. Premature and disabled infants are specific categories of children that may require levels of care that exceed the abilities of caregivers to provide a safe environment for the child. That being said, even a full-term, healthy baby’s persistent and inconsolable crying may provoke abuse. In addition, certain stages of childhood development may be more stressful for some parents to navigate than others and may precipitate maltreatment by exceeding the caregiver’s abilities to provide for the child physically and emotionally.

Family-Associated Risk Factors

Parental vulnerabilities occur in many forms. Some common examples of characteristics that are parental risk factors for abuse include mental illness, substance abuse, lack of maturity, and history of abuse. Mental illness and substance abuse can be risk factors that place a parent in a weakened state and unable to implement the necessary organizational and judgment skills to effectively parent. If a young or developmentally delayed parent lacks the requisite maturity to care for a child, this type of deficit can lead to a child’s safety being compromised. If adult members of the family have themselves been abused, they may lack the parenting skills to utilize constructive responses to their child’s behaviors as a result of their own suffering as victims of abuse.⁴⁷^–⁴⁹

Environmental Characteristics

Poverty and violence are critical environmental risk factors for child abuse. In 2005, government statistics indicated that 17% of children in the United States lived below the poverty line.⁵⁰ Although the actual income varies by family size and composition, the 2005 poverty threshold for a family of four with two related children under age 18 was $19,806. According to the most recent National Incidence Study of Child Abuse (NIS-3), children from poor families (defined as incomes below $15,000 per year) were 25 times more likely to be abused or neglected than children from families with higher incomes (above $30,000 per year).⁴⁹ In addition to greater stress on the individual family, community resources are most often limited in poverty-stricken communities that often have few or no social support mechanisms available for families in need.

Another risk factor for child abuse is family and community violence. Environments in which violence is more common may give the appearance that violence is a socially acceptable response to address or control child behavior. A 2001 study by the National Institute of Justice (NIJ) found that being abused or neglected as a child increased the likelihood of mental health concerns, educational problems, and arrest as a juvenile. The NIJ study also found that children who have been abused and neglected were at greater risk for criminal behavior as adults.⁵¹

Clinical Features of Abuse and Neglect

Physical Abuse

Child maltreatment can be deceptive and easily disguised, but for any situation in which physical abuse of a child is suspected, the AMA dictates that a thorough health assessment be conducted. The assessment should include a history, a physical examination, a developmental assessment, and related laboratory studies.^52,⁵³ Further, several findings (e.g., abdominal injuries, bruises, burns, fractures, and lacerations or abrasions) can represent physical conditions that may be indicative of mistreatment and can assist in the overall evaluation to investigate possible child abuse (Table 83-2).

Table 83-2 Physical Findings That Represent Physical Conditions That May Be Indicative of Mistreatment

Abdominal Injuries

Internal injuries without external bruises or lacerations. This could be the result of having been kicked, punched, or thrown.

Bruises

Certain patterns may be formed that indicate a particular item or article may have been used to inflict injury (e.g., a belt buckle, clothes hanger, one’s hand, or an electrical cord).

Burns

A burn pattern may indicate the agent or mode of injury (e.g., cigarettes, an iron, a coil from an electric range, or a grill), as well as immersion burns (with stocking or glove-like patterns without splash burn areas).

Fractures

Commonly seen are transverse or greenstick fractures (due to bending or direct impact), a spiral fracture (due to limb torsion), a metaphyseal fracture (which can result from shaking or pulling of the limb end), and other bone fractures (including fractures of the skull, ribs, and long bones).

Lacerations or Abrasions

Cut patterns on the mouth or lips may indicate, for example, a fist mark or razor laceration; parallel linear cuts may be from a whip or switch.

Other injuries often sustained by children who are abused involve the central nervous system (CNS). These may be in the form of subdural hematoma (which can be reflective of blunt trauma), retinal hemorrhage, and subarachnoid hemorrhage (which can be indicative of violent shaking). Although mental health practitioners may not evaluate a child with immediate injuries of this type, any of these conditions may appear as background information in the medical chart and be relevant to support the need for further investigation.^52,⁵³

Emotional Abuse

Psychological maltreatment can have devastating and long-term consequences that persist into adulthood. One definition of emotional abuse describes it as “an assault on the child’s psyche, just as physical abuse is an assault on the child’s body.”⁵⁴^–⁵⁶ Although the visible signs of emotional abuse can be hidden, a number of behavioral manifestations may be exhibited and can provide clues that a child has been the victim of emotional abuse. These symptoms often include anxiety, drug abuse, eating disorders, impaired attachments, low self-esteem, mood disturbance, poor defense mechanisms, school problems, sleep disturbances, somatic complaints with no underlying medical cause, and suicidal tendencies.^20,^23,⁵⁷ Disturbed emotional relationships in the form of disrupted attachments can have enduring negative consequences in terms of a child’s ability to function in society and possess emotional rapport with others. Attachment is a template utilized by children to explore the outside world, to develop coping styles and strategies, to regulate stress, and to use as a stepping stone to continued development and maturation. When attachment is derailed by emotional abuse, a child’s ability to trust, explore, and form healthy relationships is sacrificed in place of poor defense mechanisms and the potential for psychopathology.^47,⁵⁸

Knowing that the physical signs of emotional abuse are difficult to detect heightens the importance of other indicators that may signal child abuse. From the standpoint of the child, a clinician may notice sudden changes in the child’s behavior or school performance, difficulty concentrating (unattributable to other psychiatric causes), hypervigilance, excessive compliance, extreme willingness to please, a lack of desire to return home, passivity, disengagement, or withdrawal.⁵⁹

Neglect

Features of neglect relate to the deprivation of a child’s basic needs for growth and development. Victims of neglect can display similar behavioral, cognitive, or developmental signs and symptoms as can victims of emotional abuse. In addi-tion, there are possible physical manifestations that can jeopardize the child’s health, require immediate medical attention, and alert the physician or other provider of mental health services that the child may be a victim of neglect. These include malnutrition/undernutrition, poor dentition (to a degree that severe dental caries or infection may result), poor hygiene (to a point that adverse health consequences may result), and untreated medical illnesses.⁶⁰ An extreme form of neglect is abandonment. In this form of neglect, the parent or primary caretaker rejects all parental duties and relinquishes any role of responsibility for the child. Although society may consider this type of maltreatment more benign than abuse, victims of chronic neglect may subsequently suffer from an inability to form emotional bonds. There are many consequences of failure to form healthy attachments that include derangements in normal child development. One specific example is a correlation between lack of social relatedness and empathic expression and future antisocial and criminal behaviors.

Treatment

Early identification, intervention, and treatment are critical components in minimizing the long-term consequences of child maltreatment. Currently, treatment modalities take a multidimensional approach to target the problem from many angles (including parental psychopathology, child trauma and abuse issues, family dysfunction, and social/community supports). This multimodal approach to treatment is a relatively new phenomenon. Three decades of child abuse research have shifted the focus from individual pathology (which focused almost exclusively on the parent) to treatment and prevention that utilizes an expanded model of multimodal and disciplinary care. Comprehensive strategies to evaluate and address the numerous determinants of child maltreatment have been addressed by a number of theoretical models.^47,⁵⁸^–⁶⁰ The “ecological integration” view was first introduced by Belsky in the 1980s. He proposed a shift in the treatment paradigm from a focus on the parents or caregivers to an approach that emphasizes child and environmental risk factors.⁴⁷ Wolfe, in the early 1990s, proposed a “transitional” model that moved away from the concept of an individual psychological disorder of the caregiver and analyzed child maltreatment as an escalating problem on a continuum of cultural, individual, parental, and social interactions.⁵⁸ Another theoretical model that emerged in the mid-1990s was Cicchetti and Lynch’s “transactional” approach. Cicchetti and others postulated that numerous interactions of risk factors and protective factors between the family and society occur repeatedly over time. This model described the longitudinal interplay of these variables as a way in which individual adaptation and development is shaped. For example, they showed that rates of child physical abuse were related to levels of child-reported community violence.^59,⁶⁰

These etiological models of the last 25 years have replaced the older cause-and-effect models of child maltreatment that focused on the parent/caregiver as the central factor in abuse. In following with this broader understanding of the etiology of child abuse and neglect, current treatment focuses on the multiple pathways that may lead to abuse and the contributing situational factors (placing them in a sociocultural context, specific to each case). Current treatment modalities typically take a two-pronged approach to provide treatment to the parents and the child.

Parental Treatment

Change in parental behavior through education and training in child-rearing, child development, and the basic demands of parenting is generally offered through community mental health clinics or social services agencies. It is not uncommon that a generational cycle of abuse is present in parents who themselves have abused or neglected their children. Along with training in parental competence and parenting skills, individual therapy to address a past history of abuse of the parent by his or her caregiver may be required. Psychotherapy can be used to increase insight with regard to the maltreatment, address conflicts and relational difficulties, teach coping mechanisms for stressful situations, and provide emotional support. In addition, social supports and therapeutic services (such as parental support groups and home visits) should also be implemented to provide additional support and treatment.

Child Treatment

Maltreated children can display a host of protective defenses and are at risk for many types of psychiatric disorders, disturbances of behavior and emotion, learning difficulties, and developmental delays. Because maltreated children may exhibit a variety of responses to maltreatment, a thorough assessment and an accurate diagnosis are imperative before the initiation of treatment. Specific considerations that may assist in guiding the clinician’s choice of treatment include an assessment of the child’s developmental level at the time of the trauma and at the time treatment begins, the child’s strengths, and ongoing challenges the child is facing. Psychotherapy is frequently used to assist in relational function, to address basic trust issues, to encourage and support emotional development, and to rework maladaptive behavioral and relationship patterns. Additional therapeutic programs may address skill-building (cognitive and social), conflict management, and promotion of positive self-esteem.

ELDER ABUSE AND NEGLECT

According to the National Center on Elder Abuse (NCEA), elder maltreatment refers “to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or serious risk of harm to a vulnerable adult.”⁶¹ All 50 states, the District of Columbia, Guam, Puerto Rico, and the United States Virgin Islands have laws that govern the provision of adult protective services (APS) in instances of elder mistreatment. However, the criteria used by individual states to determine whether elder abuse or neglect has occurred, and therefore eligibility for APS services, vary widely. Some factors that vary between jurisdictions include the age of the victim; the type of abuse; whether or not neglect, exploitation, and abandonment are included; whether reporting is mandatory or voluntary (although a mandatory reporting requirement exists for most health professionals); investigative procedures; and available remedies.

Notwithstanding the differences between states in their definitions of elder abuse, most state laws include five elements.⁶² These elements are infliction of pain or injury; infliction of emotional or psychological harm; sexual assault; material or financial exploitation; and neglect. Unlike child abuse, elders may suffer from self-neglect as they age and their ability to care for themselves declines as a result of physical and mental limitations.⁶³ At the federal level, although laws exist to fund services and shelters for victims of child abuse and domestic violence, there are no equivalent laws providing these services for elderly victims of abuse and neglect. Specifically, while the federal Older Americans Act (OAA) provides definitions of elder abuse and authorizes federal funding to increase awareness of elder abuse and conduct related activities at the state and local level, the OAA does not provide direct funding to state programs that provide adult protective services.⁶⁴

Another important concern regarding elder maltreatment is protecting the elderly who reside in long-term care facilities. The Long-Term Care Ombudsmen Program (LTCOP) is federally mandated in every state, and the federal government conditions funding for elder abuse and neglect programs on the presence of the LTCOP in every state. The purpose of this program is to advocate on behalf of individuals who reside in a long-term care facility and experience some form of maltreatment. LTCOPs are the contact agency for licensed mental health professionals who, as mandated reporters, must report cases of suspected elder abuse in long-term care facilities.⁶⁵

Significant and sweeping changes in elder abuse reporting and collection may be effected by current legislation, the Elder Justice Act of 2006. If passed by Congress, the Elder Justice Act would create the first nationwide database on elder abuse. In addition, it would provide uniform collection, maintenance, and dissemination of national data relating to elder abuse, neglect, and exploitation.⁶⁵

Epidemiology and Risk Factors

Research in elder maltreatment is limited, and further study is required to better characterize the incidence and risk factors for elder maltreatment. To this end, the National Research Council in 2003 proposed a two-part definition of elder maltreatment to facilitate research about the topic. The NRC effort defines elder maltreatment as harm to a vulnerable elder that occurs either as a result of intentional actions by a caregiver or other trusted person or as a result of a caregiver to provide for basic needs and to protect the elder from harm.^61,⁶⁶ In the case of the elderly, unlike children, the elder himself or herself may be the caregiver, giving rise to the concept of self-neglect, as discussed earlier.

What is known about elder maltreatment is that elders are at risk regardless of the setting in which they reside. Elder abuse may occur in domestic settings and be perpetrated by family members, or it may affect individuals in institutions who are being cared for by unrelated caregivers. Estimates by the National Research Council suggest that 1 to 2 million Americans age 65 or older have been the victim of abuse or neglect. Elders age 80 or older are abused and neglected at two to three times their proportion of the elderly population. In addition, corroborated reports of elder mistreatment and self-neglect have been shown to be associated with shorter survival.⁶⁷ Elderly victims of self-neglect are commonly depressed, confused, and/or extremely frail.

Risk factors for elder abuse and neglect may be divided into three categories: those associated with victims of maltreatment, those associated with perpetrators of maltreatment, and those associated with self-neglect. Available evidence regarding victims of elder maltreatment includes elders living in shared situations, being socially isolated, and having dementia. Race, gender, and relationship to the caregiver may also be positive risk factors for maltreatment, but research on these factors is currently inconclusive. Positive risk factors for elder maltreatment in perpetrators include mental illness, hostility, and alcohol abuse. Other risk factors for perpetration of elder abuse and neglect need to be further studied and delineated. Finally, elders who are depressed or cognitively impaired are more likely to suffer from self-neglect.⁶³

Detection and Reporting

Physicians are mandatory reporters of suspected elder abuse and neglect, but may be inadequately trained to recognize elder mistreatment.^68,⁶⁹ Detection of the signs and symptoms of abuse may be subtle and masked by other illness or debility. To the untrained eye, elderly victims of abuse and neglect may appear to be simply frail and sick. Since the findings may be difficult to distinguish, adequate screening in health care settings is of critical importance. In addition, for many victims of elder abuse and neglect, hospitals may be among the only sources of help, placing physicians and other members of the hospital staff in the unique and important position of recognizing and addressing suspected elder maltreatment.⁷⁰ Physicians and other providers of mental health care should familiarize themselves with reporting requirements in the jurisdictions in which they practice. Familiarity with available resources for screening and investigation in cases of suspected elder abuse is also warranted.

The AMA’s Diagnostic and Treatment Guidelines on Elder Abuse and Neglect provide reference criteria to assist physicians in the recognition, diagnosis, and response to cases of elder mistreatment.⁷¹ Elder abuse is often more difficult to detect than child abuse. Social isolation is more common among the elderly, and this can both increase the risk of maltreatment and decrease the likelihood that these individuals will come in contact with health professionals. According to the National Elder Abuse Incidence Study of 1996, approximately 25% of the elder population lives alone. Many elderly have family members as their primary contacts and may have minimal interaction with others.