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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.

"The indicators or warning signs of abuse are clues that something is happening in the life of the person that should be looked into. Some indicators are obvious signs of abuse. Other indicators are subtle, requiring careful observation. In some situations abuse may not be occurring at all. It is important to think about the person and any health or behavioral issues they have. Some people may get injured more easily due to health reasons or aging. For example, some medications and some health problems like hemophilia (where the blood clots slowly) can cause easy bruising. Some people may engage in self-injurious behaviors that cause injuries that look like abuse. Even if you discover that a person has a health or behavioral issue that might be the cause of the injury, it is still important to investigate to rule out abuse as the cause. It is important to put aside any biases that you might have that care providers would not abuse a person with a disability that they support.¹"

As you interact with someone with a developmental disability, you should pay close attention to any changes in how that person looks or acts. A sudden or gradual change in appearance or behavior can be an indicator that abuse or neglect has occurred (or may still be happening.)

Physical Signs of Abuse

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Physical Signs of Neglect (in both the person and their home)

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Behavioral Signs

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Behaviors of Caregivers who may be Abusers

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:

Common characteristics among those who abuse others include:

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Profiles of Abusive Caregivers

Abusive caregivers can usually be classified into one of the following four groups:

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Types of Emotional Abuse and Neglect

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:

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Physical Abuse in Caregiving

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:

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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:

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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:

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Other Physical Indicators

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

Burns or scalds

Bites

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

Eye and ear injuries

Dental and mouth injuries

Dislocations of joints

Fractures:

Coma:

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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 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:

Number and frequency of injuries:

Size and shape of the injury:

Description of how the injury occurred:

Consistency of injury with the person's developmental capability:

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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 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

Atypical attachment
Consider:

Disclosure

Fearfulness
Victims of abuse often appear fearful of others:

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:

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

Sleepdisturbance

Withdrawal

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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 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:

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.

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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.

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

"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:

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The Problem with "Subtle" Abuse

"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:

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Conditions of People with Developmental Disabilities That Can Sometimes Look Like Abuse or Neglect

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:

  • 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 different kinds of disabilities may be overly sensitive to touch, textures, taste, or temperature. These persons may resist hugs, face washing or other harmless/innocent types of touch. This can also look like failure to thrive or significant behavioral problems.
  • Mongolian spots: Mongolian spots which are bluish or bruised-appearing areas that are usually seen on the lower back or buttocks. These spots are harmless and occur more commonly in persons of color. They may remain for months or years.8

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    Spotting the Red Flags: An Activity

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

    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.

      2. 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.

      3. 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)

      4. 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).

      5. 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.

      6. 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.

      7. 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.

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    ¹ Fitzsimons. Combating Violence and Abuse, 42.

    ² Baladerian, N.J. (1997). Recognizing abuse and neglect in people with severe cognitive and/or communication impairments. Journal of Elder Abuse and Neglect, 9(2), 93-105.

    ³ Baladerian. Recognizing abuse and neglect, 93-105.

    4 Abuse and Neglect of Children and Adults with Developmental Disabilities: A Web Course for Health and Other Professionals, Virginia Commonwealth University, (2005).

    5 Saxton, M. Curry, M.A., Powers, L., Maley, S., Eckels, K., & Gross, J. (2001). Bring my scooter so I can leave you: A study of disabled women handling abuse by personal assistance providers. Violence Against Women, 7(4), 393-417.

    6 Saxton, M. Curry, M.A., Powers, L., Maley, S., Eckels, K., & Gross, J. (2001). Bring my scooter so I can leave you: A study of disabled women handling abuse by personal assistance providers. Violence Against Women, 7(4), 393-417.

    7 Fitzsimons. Combating Violence and Abuse, 47.

    8 Abuse and Neglect of Children and Adults with Developmental Disabilities: A Web Course for Health and Other Professionals, Virginia Commonwealth University, (2005).