Report 41: Prevention in adult safeguarding
Identifying people at risk of abuse
'Risk factors associated with abuse identified within services can also help point the way for developing appropriate prevention strategies.'
A consistent theme in the literature is the value of identifying factors that indicate an increased risk of abuse among adults at risk in the interests of prevention; see for example the work of Kalaga and Kingston.(7) Identifying risk factors can help to prevent abuse by raising awareness among staff and service managers of the people in their care who may be most at risk of abuse. If staff are aware of risk factors, they can use these insights to develop effective risk assessments and prevention strategies.
This section presents risk factors identified in relation to characteristics of adult at risk, family carers who become abusers, as well as in relation to features of services where abuse occurs.
People with learning disabilitiesOpen
The literature consistently identifies people with learning disabilities as being at risk of all types of abuse. Bruder and Kroese, in their review of nine papers looking at prevention interventions aiming to teach new skills to children and adults with learning disabilities, cite authors who identify the following added risk factors: poor social skills and poor judgement, poor communication skills, physical dependence (for example need for help with personal hygiene and intimate body care), a lack of education about appropriate sexual behaviour, as well as lack of knowledge about how to defend against abuse.(15) They and others also suggest that people with learning disabilities have been educated or reinforced to be compliant, and as a result lack practice in making independent decisions in everyday life.(16, 17)
Kiekopf, reporting the establishment of a protection committee at Sense, further points to the vulnerability of deaf-blind people and people with learning disabilities to sexual abuse as a result of having learnt touch as a method of communication.(17) Cambridge and Carnaby also highlight the risks of abuse during intimate and personal care for people with learning disabilities and complex needs.(18)
Rusch et al, reported in Golding and Clear, identified six statistically significant characteristics associated with abuse.(19, 20) They found that people with learning disabilities were more likely to be abused if they were physically mobile, displayed aggressive behaviour, were young, non-verbal, unsociable or engaged in self-injury.
CSCI found that many adult at risk are reluctant to do anything about abuse if family members are responsible, for fear of losing contact with their family.(6) Women's Aid describe a similar situation for disabled women who do not report abuse.(21)
Women with a psychiatric diagnosis are identified as being at high risk of sexual abuse. Eckert, Sugar and Fine suggest that prevention strategies should be targeted at this population.(22) Adults with learning disabilities are also at high risk of sexual abuse, and often from their peers.(7)
The co-occurrence of different forms of abuse is another important factor. Wilson et al suggest that it is highly likely that a vulnerable person who is financially abused might also be being abused physically, sexually or psychologically (and vice versa).(23)
Very similar factors have been associated with increased risk for older adults. In analysing risk factors for older adults, Choi and Mayer used data from a county adult protective services unit in the US. They found that those people who were most frail and dependent were at increased risk of maltreatment.(24) DeHart et al interviewed nursing home staff, policy makers and related professionals in order to identify staff training needs.(25) They identified as most at risk of abuse those residents considered to be quiet, disorientated, unable to communicate or with few visitors, as well as those found to be non-compliant, demanding or to have difficult or challenging behaviours. They suggest that one of the staff competencies should be the ability 'to identify residents' vulnerabilities that increase the risk of their being mistreated', which does support the value of staff being informed about risk or vulnerability factors. A major UK survey of over 2000 people aged 66 and over living in private households revealed a range of risk factors, specific to the type of abuse:
- The risk factors for neglect included being female, aged 85 and over, suffering bad or very bad health or depression and the likelihood of already being in receipt of, or in touch with, services.
- The risk of financial abuse increased for those living alone, those in receipt of services, those in bad or very bad health, older men, and women who were divorced or separated, or lonely.
- The risk of interpersonal abuse (physical, psychological and sexual abuse combined) was higher for women aged 66–74, men who felt lonely in the past week, and both men and women reporting three or more depressive symptoms. There was a higher rate of interpersonal abuse reported by women who were separated or divorced. Perpetrators lived in the same household in two-thirds of the cases, and in two-fifths of cases the respondent was providing care for them.(26)
O'Dowd, in reporting on the above research, commended the findings on risk factors, saying these should be used to inform better prevention procedures and enable local authorities to monitor and act on abuse by targeting help where it is needed most.(27)
Isolation has also been identified as a risk factor for family carers becoming perpetrators of abuse in community settings – those with less family support or social contacts being more likely to abuse.(28) Choi and Mayer found that stress, substance abuse and mental illness of family carers were risk factors, as identified in their assessment of previous studies. They also identified adult children as the most frequent abusers of older adults.(24) In a paper exploring the potential of a social capital approach to the prevention of 'elder mistreatment', Donohue et al identified stress, depression, and cognitive deficits such as comprehension, communication skills and memory to be risk factors for abusive behaviour in family carers, alongside social isolation.(28)
Identifying risks in servicesOpen
Risk factors associated with abuse identified within services can also help point the way for developing appropriate prevention strategies. Most of these risk factors have been identified in relation to institutional abuse in residential care or nursing homes, partly due to the serious incidents that have occurred over the years in institutional settings. Kalaga and Kingston identified the following factors as predictive of institutional abuse:
- exogenous factors (for example bed supply, staffing rates)
- institutional environment (such as an inward looking organisation that stifles criticism)
- patient characteristics (for example very frail, challenging behaviour)
- staff characteristics (for example stress, negative attitudes, low education levels)
- neutralisation of moral concerns (leading to residents being seen as objects rather than human beings).(7)
Marsland et al conducted a qualitative study to identify 'early indicators' of abuse of people with learning disabilities in residential settings. They highlighted the particular significance of service isolation, arguing that in these situations unacceptable practices can become normalised and staff may be cut off from new ideas and information about best practice.(29)
Benbow, in reviewing 'our inability to learn from inquiries', also picked up on isolation. She identified the following common risk factors for abuse:
- low staffing levels and/or high use of agency staff
- geographically isolated services
- a neglected physical environment
- weak management
- lack of practice leadership
- lack of policy awareness.(30)
Golding and Clear, in an exploration of interpersonal boundaries between nurses and clients based on the authors' experience of working in learning disability services, identified the following risks associated with abuse of people with learning disabilities within services: low standards, poor staff morale, weak and ineffective leadership and a lack of concern about abuse by managers.(20)