 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on the abuse and neglect indicators for child and elder abuse and neglect. And that kind of doesn't even encompass everything we're going to talk about today. We're going to define terms related to sexual, physical, mental and financial abuse of and neglect of children and elders as well as disabled adults. We'll identify signs of abuse or neglect in the victim as well as in the caregivers. So we're going to learn some clues that you might notice in a parent who is abusing a child. We'll learn about mandatory reporting and identify sources for the most up-to-date reporting guidelines because they do change. You'll find when we get down there, I think it's seven states now require financial advisors as well as us to report financial abuse of elders in that we encounter. So who's a child? A child is anyone less than 18 years old. An elder is a person that's 60 years old or older and suffering from infirmities or aging as manifested by advanced age. So 75 years or older, organic brain damage that causes delirium or dementia or any other physical, mental or emotional dysfunction in which the person's ability to care for self is impaired. So if someone is older and dependent, not every person who is 60 years of age qualifies as an elder that falls under this statute for abuse. But again, this is one of those that if you've got, if you're working with a client who's 62 and, you know, overall seems to be functioning pretty well, but you find out that their kids are taking advantage of them financially or something, you really want to run it by your legal team to see if it's something that rises to the threshold of reporting. Also, not every state has mandatory reporting requirements for elder abuse and neglect. Whereas every state has reporting requirements for child abuse and neglect. So definitions real quick. A parent is a biological, foster or adoptive parent and sometimes we'll talk about primary caregiver. Adult household member found is somebody who's found in the home continually. So it can be, you know, Uncle Bob who moved in or it can be somebody who's renting a room. If that person is found in the home continually, it's an adult household member. Another adult is anyone who the child is entrusted with such as a coach or a teacher or a daycare provider. And another child is, you know, obviously another child. A disabled adult is a person 18 years or older and suffering from a condition of physical or mental incapacitation due to developmental disability, organic brain damage, mental illness, or one or more physical or mental limitations that substantially restrict the ability to function in activities of daily life. Again, thereby making them dependent. And one of the things we want to look at, even if somebody is cognitively sharp, if they are incapacitated in some way and somewhat dependent and I'm thinking of, you know, for example, Stephen Hawking, brilliant man, but he relied on other people to do things and it was, it's possible that whoever his caregiver was who was responsible for helping him with activities of daily living could have basically held him hostage and said, I'm not going to do those unless you, you know, pay me $10,000 a week or whatever it is. So there is the possible and you want to just kind of think of it is, is from the perspective of is this person in a place or condition in which they could be exploited by somebody. Abuse is non accidental infliction of physical or psychological injury or sexual abuse by a parent, adult household member or other person responsible for the care of the child. Non accidental action by a relative caregiver or household member which causes reasonable which causes or reasonably can be expected to cause physical or psychological injury or sexual abuse. So if they do something and you know, it's nothing happens right then, but it can reasonably be thought that that could cause problems later on. It could be potentially be considered abuse such as overmedicating children or giving children, young children alcohol in their bottles in order to make them sleep. You know, that could cause problems later in life or even right then and abuse is also actively encouraging another person to commit an injurious act upon an elderly person or disabled adult. So it doesn't just have to be the actor doing the acting. It can be the actor encouraging someone else to inflict harm or neglect neglect is a failure or omission by a caretaker to provide the care supervision services or protection necessary to maintain physical and mental health. We're not just talking about, you know, changing diapers and stuff. We're talking about physical and mental health. This can include witnessing domestic violence or illicit drug use for children. It can neglect concur in terms of a repeated or even a single act of carelessness that causes or can be expected to cause serious physical or psychological injury, sexual abuse or substantial risk of death. So for example, if you, you know, I know what happens where parents will leave their children who are sleeping in their crib and go up to the store and with nobody taking care of them, you know, even if they do it once that can be considered neglect because it could have been expected to cause serious physical or psychological injury had the child fallen out of the crib or something. So, you know, these are definitions and it's important to be aware of the definitions because by the definitions we make the decision about what is reportable by the definitions we need to make sure that we educate our clients that, you know, this isn't okay. You know, if we're teaching parenting skills, you know, we need to make sure that parents know where the threshold for abuse and neglect is so they don't accidentally cross that line because maybe they were raised in a in a neglectful environment so they don't understand that certain things are not okay. Threat and harm is defined as situations, circumstances or behavior which lead the person to have reasonable cause to suspect abuse or neglect has occurred or may occur in the immediate in the immediate future if no intervention is provided. So that can be a parent saying I am going to beat you senseless when you get home or if you don't do this, then I'm going to kill your puppy or whatever the situation is. So it doesn't have to be actually doing it. It can be someone believable making a very believable threat. Self-neglect omission or failure of the elderly or disabled person to maintain their own physical or mental health which is deemed essential for his or her well-being. So this needs to, you know, raise to the level in some states where the person can be involuntarily committed for example. This may also include not taking medication as prescribed and substance abuse. In Florida, we have something called the Marchman Act where somebody can be involuntarily committed to detox, to dry out and be assessed and potentially involuntarily committed by the court to treatment if their physical condition rises to a certain level where they are truly in danger of harming themselves or someone else. Not taking medication as prescribed, you know, this can occur, self-neglect can occur if somebody is for example bipolar and chooses not to take their mood stabilizers. And when they go into a full-blown manic episode, they tend to become violent or, you know, do things that could harm themselves or someone else. So in that case, that person might be in the place of self-neglect. So you need to know what your state statute says about reporting as well as involuntary commitment. Now there are all kinds of ethical issues within voluntary commitment that we're not going to get into here because, you know, you're taking away a person's rights, which can really, you know, put a damper on your therapeutic relationship and all that kind of stuff, but there are certain times where it is most prudent and obviously we know this with the Therasoft decision, etc. Exploitation. The person who exploits someone may or may not stand in a position of trust and confidence to the victim. So it can be a coach or somebody or it can be Jim Bob down the street. The person acts knowingly by deception or intimidation and knows or should knows the victim lacks the capacity to consent and this can be an elder or a child and intends to temporarily or permanently deprive the victim of funds, assets or property for the benefit of someone other than the victim. So this exploitation can be some of the scam artists that go around and exploit elders telling them that they need to buy these expensive insurance policies or whatever. Exploitation occurs in a lot of forms. Most often it's financial. So let's move on to physical abuse. That's lots of fun. Just kidding. Physical abuse. We're talking about burning, beating, kicking, punching, slapping, shaking especially infants and we'll talk about shaking baby in a minute. Misuse of medication. Now that can be for children or adults to make them sleep or to keep them excessively sedated or to get them to be compliant while you're stealing from them while you're sexually abusing them whatever. Misuse of medication does fall under physical abuse in most state statutes. Approximately 24 states have specific reporting procedures for cases of suspected substance exposed infants. Now you're saying to yourself. Well, we're not obstetricians or pediatricians. So how are we going to know these things? Well, there are times when a infant is infant is substance exposed and is not just at birth. The infant can be substance exposed through breast milk for some drugs. The infant can be substance exposed willingly by the parent who gives it, you know, Xanax or alcohol or something to get it to sleep. So you need to be aware. If you hear the parent talking about struggling to cope with the child or needing to get the child to go to sleep or bad colic, you know, you want to investigate to make sure that the child is safe. Lots of children have bad colic. You know, don't don't get me wrong. That's not an indicator that anything is wrong, but if the parent is struggling with it, you want to make sure that, you know, things are going okay and the parent has the resources to deal with it. Standard reporting procedures apply in those states that statutorily define infant drug exposure as child abuse and neglect, but have no specific reporting procedures for substance exposed infants. So even if the state statute doesn't say, okay, for substance exposed infants, you need to do X, Y and Z. If the state statute says that infant drug exposure is child abuse and neglect, then it's a standard report. Physical indicators of physical abuse, unexplained bruises or welts on face, lips, mouth, torso, back, butt, and thighs. A lot of times abusers will learn how to strike a child or injure a child where they leave no marks. So this is not a definitive thing. You want to look for any bruises or welts that are in various stages of healing that make be clustered or form regular patterns or reflect the shape of an object used, like a belt or hands, especially on the arms if you see handprints on their arms or on a child's butt or back. You also want to be especially aware if there are bruises or welts on several different surface areas, regularly appear after a child has been absent for a while over the weekend. You know, on Mondays, they tend to have more bumps and bruises or after they've been on vacation. Again, some children are more rambunctious than others. So it just because you're seeing bumps and bruises and every Monday the kid comes in and they're sore and they've got bruises doesn't necessarily mean they're being abused. It could mean that they are learning how to skateboard or, you know, they're involved in some sort of activity. My kids are in martial arts and they have sparring on Saturdays and judo on Sundays. So generally, you know, they end up with a bruise by Monday morning, but we want to look at the breadth of, you know, how frequent are the bruises? How bad are the bruises? You know, one bruise, you know, that's not a big deal. If they have bruises all over their body, that's something else. They may have unexplained burns on the soles of their feet on their palms on their back or on their buttocks. You also might see immersion burns. Sock like burns from taking somebody's foot and sticking it in a scalding hot bath of water. So it looks like they've got a red sock on the same thing for hands. You might see glove like burns. Donut shaped burns on their but or genitalia, which, you know, could result from sitting them in something hot. So there's the circular burn where they're where their keyster hit the hot water. Pattern like electric, electric burners or irons. So the hot stove or a curling iron or a regular clothing iron and rope burns. You want to look on arms, legs, torso and neck for any evidence of rope burns or anything that might have been used to restrain the child or adult unexplained fractures in various stages of healing or multiple spiral fractures. It is not easy to get a spiral fracture. You don't get a spiral fracture from gymnastics most of the time. I mean, I can't really think of a time you would every once in a while. You may get a wrestler may get one, but they should be, you know, you know, once in a lifetime, not once a semester. So we want to look at the frequency of any fractures that might be having any unexplained lacerations or abrasions. So cuts and cuts and scratches. And again, people might think that, you know, something awful happened to me some days when I go out and I weed around my pond and I don't wear long sleeves when I leak weed because it's really hot. So I'll if they're lucky I'll wear gloves, but I'm going in all the reeds and I come out and I will have scratches stuff all up my arm. Is somebody abusing me? No. So you want to look at kind of what happened and investigate it. Could it have come from the child going hiking or something and again, how frequently does it happen? If it's just once, okay, if it is repetitive, you may want to look at what might be causing it and any signs of confinement, including bed source for children and adults. If they're you don't move enough, you can get bed source. You also want to look for wasting of muscle and decrease in coordination. I'm thinking about that family in California that had their kids basically chained up for 20 years or something. You know, obviously. Evidently they went out to Disney World and they went other places. They didn't get out a lot. So it's important that when people do get out, we do notice. Unfortunately, we might not see some of these things. We also want to look for injuries that haven't been cared for properly or that are incompatible with the explanation. If they have a black eye and they say, I ran into the corner of a wall, you're not corner of a wall is going to give you a distinct mark. If there's pain on touching them, you pat a kid on the back because they did a good job or something and they're like out. Oh, that really hurts. Do they have a sunburn? Maybe. Do they have bruises? Could be. Look for dehydration or malnourishment or loss of weight that's not illness related and that includes eating disorders. So if a child starts to look really drawn and gaunt, if they have bad pallor, sunken eyes or cheeks or anything like that, we want to be questioning, you know, kind of what's going on. Same thing for elders. Now, as we get older, we lose fat and stuff in our face. So we look a little bit more drawn. That's normal aging for some elders when they get sick, you know, since they don't have near as much fat and stuff. If they get the flu, they may look really drawn for a little while after they've had the flu. We just want to investigate and watch it. If they show up to session and they're looking, you know, pretty rough, ask them how things are going, do a safety check and then keep an eye on it. The next time they come, are they looking better? Because it can be due to other factors. Shaken baby. Now, shaken baby, if you remember, is taking an infant, especially one that doesn't have good neck muscles yet, but even older children that have, you know, can hold their head up on their own. You know, you shake them hard enough. It's going to basically give them whiplash signs you might look for. Now, again, we're not pediatricians, but you can have parents bringing children in two sessions. You can be encountering parents. So you want to look for things and you want to listen if the parent starts describing some of these symptoms because it may not be the client you're working with who shook the baby. It could be somebody else in the household. So it's not always the client we're working with who is the perpetrator or the victim. It could be somebody else. So extreme irritability and high-pitched crying can happen for a lot of reasons, but that's one sign. Lethargy or poor feeding, vomiting without obvious reasons, and if you're thinking, you know, the symptoms of a concussion like you would look for in a adolescent who plays football or something, you know, a lot of them are the same here, but the baby can't articulate loss of social engagement. They're not smiling or cooling. They're just kind of blank poor suck or swallow coordination, unusual breathing patterns, and it can be really rapid or really deep and consistent, but it's not a normal breathing pattern for that child bruising of the body due to the grip strength of the individual. So looking on the shoulders or even on the abdomen, because sometimes people will grab the child by the rib cage and shake them like that. Seizures, which can be caused by increased cranial pressure, head trauma, bruising, swelling, deformity of the skull. Obviously, if there's a skull fracture, that's what you would call a clue. Now, remember again that babies fall and just because they have a bruise or a swell. I know my, my son got a couple of good goose eggs when, when he was little falling and hitting the corner of a chair or something. So we don't want to assume and accuse people of wrongdoing right away. We want to put all the clues together, but bruising, swelling, skull deformity. Now things to really be concerned about if the, there's an inability of the infant to track or focus on an object at the appropriate distance for that infant. Remember real young ones can't focus very far away from their face, but you want to see them tracking an object. If they have unequal pupil size, I don't care why it happens. If they've got unequal pupil size, they need to go to the emergency room and be evaluated. An abnormal increase in muscle tone, especially about the neck. If the baby is regularly being shaken, they may have an abnormally strong neck. Hemorrhages of the retina. If you see bleeding in their eyes, you know, babies aren't supposed to have bloodshot eyes and definitely not bleeding in their eyes. Bleeding or drainage of clear fluid from the nose or ear canal. Obviously you can get a runny nose and have clear fluid coming out. We want to just pay attention and any developmental delays as the child gets older. If he or she was shaken as an infant, then they may not develop as expected because they do have organic brain damage. Behavioral indicators of physical abuse. The person, especially a child, may be wary of adult contacts. Elders may be wary of other caregivers coming in to work on them or work with them. They may be apprehensive when seeing other children cry because a lot of times if a child is getting abused, then they get punished for crying. I'll give you something to cry about quote unquote. Behavioral extremes. You may see the child become very aggressive or on the other side withdraw and just blend into the wall because they don't want to call attention to themselves because that's the safest way to not get hit. Some children will vacillate between both of these between being really aggressive and withdrawn. They may be frightened of parents or caregivers afraid to go home or they may flat out report injury from their parents. Sexual abuse. The term sexual abuse includes the employment use, persuasion, inducement, enticement or coercion of a child to engage in or have a child assist with any other person engaging in sexually explicit conduct. Now just reading that makes me want to go take a shower because it's just awful. So let that sink in, not just the child doing the conduct, but the child can assist other people in engaging in the explicit conduct. Any simulation of the conduct for the purpose of producing a visual depiction of the conduct. Child pornography, the rape, molestation, prostitution or other forms of exploitation of children. So pretty self-explanatory. Children cannot consent. So any of this really falls under sexual abuse and it can be touching, fondling all the way through full sex acts. Elder sexual abuse is defined as an action against an elder that is unwanted and sexual in origin. It involves those older than 60 and includes any sexual contact with an elder or disabled adult, so elder or disabled adult who because of mental illness or dementia can not communicate their disapproval of the behavior against them or can not communicate their consent for the activity and I will add on here or cannot get away from it. So even if they can communicate their disapproval or lack of consent if they are not able to physically get away from that person, maybe they're bedbound and they can't get to a phone because they are bedbound. You know, obviously that would be sexual abuse in 21 states. The definition of sexual abuse includes human trafficking, includes sex trafficking or trafficking of children for sexual purposes. So this is one of those new things that we've added human track trafficking of a child for sexual exploitation includes all forms of commercial sexual activity with a child, including prostitution and the participation in the production of pornography. Human trafficking is one of the fastest growing crimes in Tennessee and I think probably in a lot of states in the nation, so it's important that we're more aware of this. In 25 states, Guam and the northern Mariana Islands, the term commercial sexual activity includes sexually explicit performance, such as performance in a strip club or exotic dancing or display. So having a small child do a strip tease or some sort of exotic seductive dancing or display, especially for compensation would be what may fall under this statute. Sexual exploitation includes allowing permitting or encouraging a child to engage in prostitution or allowing permitting, encouraging or engaging in obscene or pornographic photography, filming or depicting a child for commercial purposes. Physical indicators of sexual abuse and this is for elders and adults difficulty walking or sitting, torn, stained or bloody under clothing, pain or itching in the genital area, bruises or bleeding in external genitalia, vaginal or anal areas or to the inner thighs, venereal diseases and obviously in females pregnancy. So these are all things that we want to be aware of. As clinicians, we may only become aware of some of the more obvious walking sitting. We're not going to necessarily see the bloody under clothing and but doctors can also be encouraged to look for any signs of sexually transmitted diseases during physicals, annual physicals. Behavioral, more behavioral indicators, unwillingness to change clothing or participate in gym class, withdrawal, fantasy or infantile or regressive behavior. Sometimes children will, you know, start sucking their thumb again or become much more infantile if they're being sexually abused. Bizarre, sophisticated or unusual sex sexual behavior or knowledge, poor peer relationships, delinquency or true runaway, age, inappropriate sexual play with toys with themselves with others and with younger kids. So you want to kind of pay attention to any sort of sexual acting out or demonstrations by the child. Comments such as I've got a secret or I don't like uncle can also indicate that there's a problem. Now kids have secrets, you know, that they tend to like sharing secrets and stuff. So we want to find out what kind of secret it is and make sure children know the difference between, you know, a bad secret and an okay secret. Some boys will become, we'll start with fire lighting. Children, well, and adults may fear certain places such as the bedroom or the bathroom. So if you're thinking of a adult with a cognitive disability, you know, they may demonstrate extreme resistance to going into certain rooms or going to certain places because they've been traumatized there before. Look for eating disorders in both boys and girls, promiscuity or prostitution, making oneself as unattractive as possible. Sometimes this is a reaction either eating to the point of extreme obesity or forgoing any sort of activities of daily living, daily health, hygiene behaviors can be a sign of sexual abuse. Unexplained accumulation of money or gifts. This is one of those big red flags. If all of a sudden they're showing up and they've got new jewelry on or they've suddenly got a lot of money that, you know, they're not even old enough to work yet, you're going, you know, where did that come from? Be aware. But even if they are old enough to work, it is not uncommon for youth to get in situations where they can be exploited as they get older. Overly compliant behavior may be evidence of grooming. So if they're willing to do things that they don't want to do, if they're willing to dress up a certain way, if they're willing to do certain things that normally a child of that age would go, uh, no. You want to pay attention. If the child starts having nightmares, mood swings or evidencing self-injury or suicidal ideation, these could also be behavioral indicators of sexual abuse or a whole host of other things, but it definitely tells you something is not right. Adult behavioral indicators. If an adult that is responsible for the child is the one perpetrating the abuse, then the child, the adult may be unusually overprotective of the child. You know, they want to keep the child close because they want to make sure they know what the child is saying and they're kind of looming over that child all the time. The adult may be jealous of the child's relationship with peers or other adults and can be really controlling of the child. They may favor that victim, that particular child over other children in the family or demonstrate physical contact or contact or affection to that child, which appears sexual in nature or has sexual overtones. And that can include back rubs. That can include inappropriate touching. That can include inappropriate kissing. Just being aware of the surroundings. Sibling behavioral indicators. Now, this is the only one that really siblings are generally thought of. Although siblings, siblings can perpetrate physical abuse. It's less common. Behavioral indicators of siblings sexual abuse include siblings who behave like boyfriend and girlfriend. A child who fears being left alone with a sibling. Siblings who appear to be embarrassed when found alone together or one sibling antagonizing the other. But the other one's not retaliating because they're afraid that mom and dad are going to find out. So we do want to look at the chance that this can happen. The siblings are in a perfect position if you will to groom their younger siblings for this kind of behavior. Should that be a predisposition? Mental abuse. Physical indicators of that mental abuse may be occurring. And this is anything where the person is being belittled. Told they're worthless, being harassed. We'll look at speech disorders. Failure to thrive. If somebody is being continually told that they're worthless, they're of no value, etc. They may become very depressed and not take care of themselves, not eat, not do those sorts of things. Bedwetting or soiling that has no medical cause. This can also be an indicator of sexual abuse. Frequent psychosomatic complaints such as headaches, nausea, abdominal pains. If the child has not attained significant developmental milestones, if he or she is dressed differently from other children in the family or has deprived physical living conditions compared with other children in the family. So sometimes there may be a child that gets, you know, sent to live in the attic or in the basement because it's that child is considered the black sheep of the family. And those are the things that we want to look at. Does this child have all the same experiences and opportunities as the other child, children in the family? Other psychological indicators of mental injury include ambivalence, deference, passivity and shame. And if you're told you're not good enough, if you're told that your parents are sorry that they ever had you, you know, and anything else that they might say that can be considered mentally abusive. It's probably going to take a toll after a while because it's coming from your parents. So they can be very passive and very ashamed and not, you know, feel like they're not worth anything. They can be confused, disoriented. They may be trembling, clingy, cowering or have a lack of eye contact. Now remember, we're talking about elders, disabled adults as well as children here. So if you see an elder get really nervous when you ask a question or when somebody walks into a room, we want to pay attention to what's going on. If there's evasiveness in older children or adults, agitation or anger, hypervigilance, we're looking at signs of, you know, potential PTSD here. So, you know, that should give us a clue that something's not right. If the person has sudden symptoms of resignation, they just, whatever, it's never going to get any better. If they have implausible stories about things that are going on, if they make contradictory statements or they're just flat non responsive, these can all be indicators of mental injury. Now, a lot of times you don't just have physical abuse or sexual abuse or mental abuse. A lot of times there are multiple types of abuse that are going on. So if the person's being physically abused as well as mentally abused, for example, they may also deny that anything's going on because they feel, for example, that they caused it or they brought it on themselves. In children, we also may see habit disorders such as sucking, biting or rocking, sleep disorders, behavioral extremes, severe developmental delays, depression, anxiety, withdrawal or aggression, self destructive behavior, being overly compliant and too well mannered, you know, trying to please in order to get any sort of positive regard, displaying attention seeking behaviors or extreme inhibition in play. When at play, the child may model or copy negative behavior and language used at home. So if you see them playing dollhouse and they're the two characters are screaming at each other and yelling obscenities or something, then you have an idea about what the child may be may be seeing at home. In adults, we want to look at things that might be going on, you know, if the adult caregiver calls the person, child elder adult calls the person names, labels him or her publicly or humiliates him or her. That's mental abuse. If the adult, the perpetrator continually threatens the person with physical harm or forces the person to witness physical harm inflicted on a loved one or a pet. Mental abuse. If the perpetrator has unrealistic expectations of the person, unrealistic expectations of children, you know, you can that's easy to think of, but also think of people who are cognitively impaired or elderly or disabled in some way. We have to have realistic expectations and sometimes especially for people who have dementia or Alzheimer's caregivers can get very frustrated very easily. Because it just seems it is specifically regarding children, another adult behavior could be involving the child in adult issues such as separation, pitting the child against the other parent or putting them in a position where they have to choose between two parents or keeping the child at home in the role of a subservient or surrogate parent. So neglect can include substance misuse, inadequate supervision, environmental neglect, you know, letting everything go to hell in a handbasket, no food in the refrigerator, no clean clothes. Lack of health care, threatened harm, other special conditions, failure to protect and death. Physical indicators of neglect include consistent hunger. If the elder person is always hungry or the child comes to school and is just always ravenous, poor hygiene, inappropriate dress for the weather, or, you know, and this can kind of go along with poor hygiene, being in the same clothes two, three, four days on end. Consistent lack of supervision, especially in dangerous activities or for prolonged periods of time, you want to make sure that the child is being observed. You don't want a two-year old walking around a lone in a neighborhood. Unattended physical problems or medical needs, alcohol or drug abuse by the victim, if you will, can indicate that there's neglect because they can access it and or because they're trying to escape and numb some pain and abandonment. So behavioral indicators, begging or stealing food, extended stays at school, you know, the child gets there early and leaves late. Now that can be one extreme. If the child can get him or herself to school. The other extreme, which is more common, is poor school attendance and poor school performance because they're not getting enough food so they can't focus and their parent is not regularly getting them to school and maybe something else is going on at home where the child is up until one, two, three in the morning. So they're not getting enough sleep, they don't wake up for the bus and then they miss school. Constant fatigue, listlessness or falling asleep in class. We want to figure out why this is that is not normal for children, especially, you know, younger children. I know when I was in high school, by the time we got to seventh period, I was like, you know, having everything I could do to stay awake. I don't know if it was because it was seventh period or because it was trigonometry, but either way, sometimes it's normative, but other times, especially if it's all day every day that the child is like this, we want to find out why. If they become delinquent, you know, stealing things, falling in with the wrong crowd could indicate that there was neglect at home. So they were looking for approval from another group. If the child states that there is no caregiver, you know, we want to explore that. Is the child a latchkey child? So they get home and mom and dad don't get home for three hours or they get home and mom and dad don't get home for three or four days because they went on a vacation somewhere. And this happens in regardless of socioeconomic status. So don't be fooled into thinking it's just one group of people. I know some very wealthy people who, you know, occasionally will just up and go on vacation for two weeks out of the country and leave their younger children at home under the supervision of the 16 year old. You know, whether you agree with that or not. And that's just since I've known them. I don't know, you know, how young the children were when that started. But you know, paying attention to those sorts of things and identifying what's going on. If there's a severe lack of attachment to other adults, poor social skills, if the person is very demanding of affection or attention or has no indication of basic hygiene, children have to learn basic hygiene. So if they grew up in an environment where nobody was ever telling them to take a bath, then, you know, they may not they may get to high school and still not realize the importance of it. And yes, it is important to approach any of these issues with an air of compassion and to find out what's going on because so many things can cause any one or two or three of these symptoms that aren't abuse or neglect. I mean, the child could be clinically depressed. The there could have been a death in the family. The child could, you know, there are a lot of different things that could be happening. So we don't want to start out by saying you're doing something wrong. We want to say, you know, I'm really concerned because Johnny has shown these behaviors or something. Financial exploitation of elders and disabled adults can't really exploit a two year old financially. So what does that look like? It looks like excessive banking activity where the elder is regularly giving people, you know, or a person, you know, large sums of money for that person. You know, $10,000 may not be much to some people, but it may be the entire life savings for another person. So we want to look at it proportionally. If the caregivers have documents drawn for the elder to sign, especially those that include power of attorney or ability to access their financial accounts, the living situation is not commensurate with the elder's estate. If you've got somebody who's, you know, relatively stable, not necessarily just well off, but, you know, low middle, middle class, middle SES and they are living in, in squalor, you know, you want to go, where's all that money coming from? You know, your social security is $2,000 a month and you're living in a, you know, $300 a month trailer somewhere. What's up with that? Or the caregiver expresses concern over the elder's financial status and personal belongings. This is kind of when they start looming and going, that's going to be mine as soon as you die. And that's going to be mine and I want to make sure I'm in the will. So we want to be cognizant of those things because it can happen. Refusal to spend money on the adult or the elder. So if the caregiver is going, yeah, you know, I know that the person might benefit from this, but that's really expensive. I don't really want to go there because in their mind they're seeing their inheritance whittling down. If the person expresses gushy, undying affection towards the elder, this can be a warning sign because it may be the person trying to ingratiate themselves with the elder to get a bigger piece of the pie. It may be them trying to ingratiate themselves so they can exploit the elder and get money now. So they don't have to worry about whether they're in the will. A lot of things can come up. A lack of amenities making sure that the elder has, you know, food in the house, not that they're relying on, you know, somebody to bring them their meals every day. Now, some people have meals on wheels and that's a whole different story. But if the person is reliant on someone else to make sure that they have power turned on and make sure that they have food in the house, then that can be held as a bargaining chip, if you will, to exploit money. If the caregiver tries to isolate the older adult from friends or family or maintains total control and this can be a nurse caretaker type person. This can be or it can be maybe a second spouse and or maybe even a first spouse. But if they try to isolate that person from the rest of the family and take control of the finances and basically financially bleed the person dry before they before they die. That could be considered exploitation. If there's promises of lifelong care for deeds and accounts if you sign over this account to me then I'll take care of you forever or pay attention to documents that are signed if the elder can't write. Some people my grandfather for example had Parkinson's really bad towards the end of his life and he could not sign anything. He couldn't even hold a pencil. So if we would have seen a document that was signed by him it would be a little bit suspect. So we want to pay attention to those things. If the elder is not given the opportunity to speak without the caregiver being present or if the caregiver cuts them off you know the caregivers present and you ask the elder a question and the caregiver answers for them. That may be an indicator that the caregiver is trying to conceal something. If the caregiver exhibits high levels of indifference or anger towards the adult it may also indicate exploitation because the caregiver is feeling exhausted and feeling entitled to money or funds or whatever and and may not feel like they're getting everything they deserve and when people get into that state is when they're really vulnerable to exploiting other people. And if you notice that the patient is being over medicated or sedated. Now I will put in my little 15 cents here that there are a lot of medications especially pain killers and benzodiazepines that do not clear the system of older people the same as it does younger people. So it is easy unfortunately for older people to develop toxic levels of and or super sedating levels of benzos or opiates in their system. So it's really important to make sure if they're seeing a doctor and on these medications that the doctor is schooled you know as a geriatric specialist because of those issues. So just because you have an elder that you know maybe they came out of the hospital and it's been three weeks and they come in for an appointment or you go to a home visit and they're slurring their words and kind of act and drunk and out of it doesn't necessarily mean that they intentionally took too much or that their caregiver gave them too much it could be that their liver couldn't clear it quickly enough. Again now I don't want to under report you know I want to encourage you to be alert to all these signs but always think don't always assume the worst always ask yourself what other things do I need to rule out that could be going on here. Factors which contribute to child abuse and neglect socioeconomic status stressor stressors when people have a lot of stress in their life it is easier to have a short fuse and lash out parental inability to cope regardless of socioeconomic status if parents are having difficulty dealing with life on life's terms then when Johnny asks that 47th but why question you know the parent may lose control. So it's important for us to be aware of those sorts of things substance dependence or abuse can lead to a lot of abuse and neglect whether it's because the parent is emotionally or physically unavailable whether it's because the parent is bringing people into the household that abuse neglector exploit the child whether it's because the caregiver is exploiting the child to get money for drugs there's a whole lot of reasons that substance abuse can be connected with child abuse now there's also parents who are functioning alcoholic so to speak and in other other terms where they're using and they are not neglecting or abusing their children so I don't want to give the impression that everyone who uses abuses or neglects their children but there is a much higher risk marital problems add to that stress that can cause a short fuse job-related stress and family violence that already exists if the adults in the family are violent towards one another it is not a huge step to see that the adults being violent towards the children factors which may contribute to elder disabled adult abuse or neglect chronic self-neglect by the adult or elder because the person may you know get frustrated that you know grandpa never goes to the bathroom when they're supposed to dementia if the client has dementia a lot of times they will do behaviors that don't seem to make a lot of sense and it's difficult to communicate with somebody who has dementia sometimes if the person has a lot of chronic illnesses it's exhausting to take care of them the and the caregiver may not give enough food so the person may become malnourished if there's over medication or medications available it can make it easier or more tempting to pacify the older adult if the older adult has depression or if the caregiver has depression or substance abuse it can lead to exploitation again to get money for drugs because they're bringing in unsavory characters who are going to exploit the elder disabled adult or child in the household poverty can contribute to elder abuse same reason as with the children the financial stresses can make it more difficult for the caregiver to deal with life on life's terms and isolation if the care if the elder person is not getting out so nobody's going to see the bruises or the malnutrition then it's easier for the caregiver to kind of slide so it's important to make sure that the elder is getting some sort of contact and being seen reporting now the florida example chapter 415 of the florida statutes provides a central abuse registry most states have these it defines who must report abuse and assigns the department of children and families all responsibility for receiving investigating and acting on all reports and I've told you in other classes that sometimes when there's a question about does this rise to the threshold of abuse reporting I would call the abuse hotline and without giving names I would say this is the situation it does this rise to the threshold where you will take a report and if the person on the other end says yes then I give them all the pertinent information and by the being it's done if the person on the other end says no then I still get their badge number to put in my case notes that says I called the department of children and families told him what was going on they declined to take the report that protects me so for adults as far as abuse reporting there is a regularly updated document for each state and Stetson University keeps this one and you can just go through and click on whatever state you're in it tells you what the terms are what neglect is defined as how you have what the liability for acts of another person are what you're supposed to do etc so real good synopsis of what needs to happen for elders same thing for youth and as I told you earlier Delaware, Missouri, Washington, Alabama, Indiana and Vermont now require the the reporting of financial abuse so that would include from us but also financial advisors and the Child Welfare Information Gateway keeps a updated document well relatively this was updated in 2016 of state statutes for who has to report all of these documents are in the additional resources section of your class if you want to take a look at those immunity from liability well, you know, we're breaking confidentiality when we make these reports and it could potentially damage our relationship with the client one of the things that I try to do is get get the client to make the report themselves in my office you know, I'll say, you know this is something that's going to have to be reported now I can do it but it would probably be better if it came from you and I can sit there while they make the report empowering them to take control of their situation sometimes it is too dangerous for whatever reason to notify the abusers so if you find out that your client is abusing their child at home telling them that you're going to make a report before you make the report could put the child in imminent danger so each situation you need to consider on an individual basis but as far as liability when we start breaking confidentiality and making these reports which some people perceive as slanderous if the report is made in good faith we're immune from civil or criminal charges so in good faith we really want to make sure that we've got documentation supporting these are all the reasons that I thought abuse or neglect was going on ideally consult with a colleague before you make the report unless there's like pressing imminent danger consult with a colleague and go you know, what do you think about this and you know, if it is one of those situations where you're not sure if it rises to the level call the abuse hotline and get their impression the reporter's name whoever makes the report will not be released to anyone other than the Department of Children and Families or whatever it's called in your state the state attorney's office or with written consent of the reporter in most states now the caveat comes from the fact that once it's released to the state attorney's office and it becomes a case then it becomes more public record and the reporter's name likely will be in there but the Florida law is designed to protect people to encourage professionals to inform families that they are obligated by law to report so we want to tell people that this is going to happen and ideally before again before you make the report but but not always and we want to make sure that we are reporting and we're not going I'm afraid I'm going to be sued the welfare of the child the elder or the disabled adult is more important as long as you're making the report in good faith so how to report in Florida you call 1-800-96-ABUSE 24-7 generally whatever hotline you're calling they want names and addresses of the people involved the age race sex of the perceived victim the nature and extent of alleged abuse the identity of the abuser if known other information is applicable and the child or adults location at the time of the report so if the child sitting in your office and safe then you can tell them that if the child is at home and your client is the abuser and just left you can tell them that a lot of times with child abuse they will end up cross reporting to law enforcement so there are mandatory reporting laws for children elders and adults with certain disabilities the laws regularly change so it's important to regularly check check your state statutes it doesn't take long you know once a year or once every other year just check in with your state statute ensure that front desk staff in addition to clinicians are aware of the signs of abuse because you may have you know a caregiver come in with two children in tow one child is seeing the therapist and the others are out in the waiting room and what the therapist sees in the clinical session may not indicate any signs of abuse but you know the parent may evidence signs of abuse in the waiting room or the parent themselves may evidence signs of domestic violence so we want to make sure that our front desk staff is alert to these things and can alert clinical staff so the correct steps can be made remember that many things can cause individual symptoms so it's important to thoroughly assess behaviors and what's going on again like one of you said not to villainize the parents or the clients but to look and say what's going on here there is something not right that you know it feels like something's wrong the child is struggling or the elder is not doing well how can I help and proceed from there to see what can be done to advocate for the potential victim all right that was a lot of legal stuff is there anything else that you want to share that you want to suggest and yeah it is a big problem I remember when I worked on in the I had multiple clinics in Florida and there was one county I went to and I didn't literally did not go in an entire week without making an abuse report for over a year so we do want to you know recognize that it does happen and look for the signs that that might be going on as well as educate other people so they can be aware and educate a lot of abuse is not a malicious person trying to hurt a child but a person who is not coping with life very well and has difficulty with anger management and difficulty controlling themselves and the child gets in the way or becomes the outlet for their distress so you know sometimes providing prevent prevention education parenting skills all those things can help avoid or reduce the incidence of child abuse as well as respite centers and I know we've got a lot of them popping up around here which are really nice they're just drop in day cares so parents if they're having a particularly stressful day or a particularly bad day they may be able to drop the child off so they can have two or three hours some of our libraries have family areas and the whole quarter of the library is kind of cordoned off so parents can come and there are beanbags and stuff for the kids to play on and there are kids kid appropriate games on the little computers there but parents don't have to be looming over their children it can give them a little bit of a break because being a stay at home parent with a very small child or multiple small children can get really stressful so having these outlets where parents can just get out and be around other people can be very very helpful all right everybody well thank you for being here on Tuesday and you know dealing with a very kind of frustrating and depressing topic the good news is that we can affect change so I will see you all on Thursday if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allCEUs.com slash counselor toolbox this episode has been brought to you in part by allCEUs.com providing 24-7 multimedia 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