Investigating Suspected Elder Maltreatment
Holly Ramsey-Klawsnik, PhD
ABSTRACT. Thorough investigation of reported cases or elder maltreatment is necessary to determine the validity of the allegations and to identify victims to whom protective services should be offered. This paper discusses the process of a comprehensive investigation, including the goals and steps involved. Information which should be elicited from reporters, collaterals, and existing documents is identified. Guidelines are provided for interviewing suspected victims and offenders. Specialized diagnostic evaluations may aid in determining the validity of allegations and assessing the impact of maltreatment on the victim. Clear, detailed documentation of findings is necessary, as is careful decision-making concerning whether or not to substantiate the allegations. Guidance is provided for completing these investigatory tasks. (Single or multiple copies of this article are available from The Haworth Document Delivery Service: 1-800-342-9678. 9:00 a.m. – 5:00 p.m. (EST).)
Careful, thorough investigations of reported cases of alleged elder abuse is a critical step in the provision of services to maltreated elders. Reporting and investigation are the processes through which elder victims of abuse and neglect are identified so that services can be offered to prevent further harm. While procedures for reporting suspected cases of elder abuse and neglect have been studied and discussed (for example, Clark-Daniels et al., 1989; Daniels et al., 1989; Faulkner, 1982; Fredriksen, 1989), procedures for investigating these reports are less well addressed in the professional literature.
It is crucial that those responsible for assessing allegations of elder maltreatment conduct thorough investigations and reach conclusions based upon accurate and comprehensive information. Improper, incomplete investigation can lead to two possible errors: failure to substantiate (find the allegations to be valid) in a case of actual maltreatment, or alternatively, substantiating a case as one of abuse or neglect when in fact no maltreatment has occurred. In the former situation, an elderly individual who is being harmed by abusive or neglectful actions is unlikely to receive necessary protection. In the latter, services may be delivered that are not warranted (such as removal from a caregiver erroneously believed to have harmed the individual). Built errors are serious and can result in grave negative consequences for the involved elder and caregivers. Sharon (1991) reports that 57% of reported cases investigated in Wisconsin during 1988 and 1989 were substantiated. Tatara (1993) reports that in 1990 and 1991, 54% of the reports investigated in domestic settings were substantiated in the approximately thirty states studied. While substantiation rates have been used as a measure of accuracy in reporting (Sharon, 1991), whether or not the substantiation decision is accurate is directly linked to the quality and thoroughness of the investigation undertaken.
In the role of consultant and staff development trainer to Adult Protective Service (APS) systems, the author has had the opportunity to collaborate on a number of elder abuse investigations, to consult on many others, and to serve as a case reviewer in situations involving protective service provision to maltreated elders. The result of these experiences has been the opportunity to examine (and contribute to) investigatory policies and procedures in a number of states. In serving as a consultant and case reviewer, mistakes can often be retrospectively detected, particularly when an undesirable case outcome results. Consultation and record review also offers the opportunity, to observe policies and procedures that contribute to the effective and thorough investigation of maltreatment allegations. This paper has been greatly enriched by these experiences. It discusses the process of a thorough protective service investigation, including methods of investigating suspected elder physical abuse, sexual abuse, psychological abuse, and neglect. The information presented is also applicable to investigations of alleged financial exploitation, although this type of investigation in addition warrants extensive review of financial records. Heisler and Tewksbury (1991) and Blunt (1993) provide guidance in this area.
Typically, APS social workers investigate reports of alleged elder maltreatment. Due to collaborative or contractual relationships, law enforcement officers and medical, mental health, and social work professionals may conduct some of the required interviews or collect other evidence. Reports of alleged elder maltreatment rose 94% from 1986 to 1991 (Tatara, 1993). Most APS systems are overtaxed and struggle to adequately protect their abused clients with inadequate budgets, not enough staff and too few community resources (such as adult day care and nursing home beds). This combination of a high number of reported allegations and a shortage of resources for assisting maltreated elders increases the importance of informed, accurate substantiation decisions. Professional investigation and careful decision-making regarding whether or not to substantiate allegations will do much to insure that services are made available to appropriate recipients.
Goals of the Investigation
The overriding goal of the investigation is to prevent further harm to the elder who may have suffered neglect or abuse. In order to accomplish this, one must determine if the referred elder has been maltreated. If so, the nature and extent of abuse should be explored, and an attempt made to identify the individual(s) who have perpetrated the abuse. An additional goal is to assess how and in what ways the maltreatment has affected the victim (Table I). A service plan is designed to prevent further maltreatment and to ameliorate the negative effects of the abuse previously suffered. At the completion of the investigation, (sooner in emergency situations) services are provided if the individual accepts them. Services are not and cannot be provided if a competent elder refuses, even if that individual is being mistreated. Elders who are deemed legally incompetent to make informed decisions are appointed a guardian to oversee their interests. Guardians have authority to accept or reject services on behalf of the elder.
Goals of the investigation
- Determine if the elder has suffered abuse/neglect
- Determine the nature and extent or maltreatment
- Identify the perpetrator(s) or any abuse
- Assess the impact of the abuse on elder’s functioning
- Plan intervention to prevent further abuse
- Plan removal service, to help the elder recover
Intake and Screening
To accomplish investigatory goals, a variety of steps must be taken (Table 2). The first is intake and screening. The individual reporting the suspected maltreatment (the reporter or referral source) will be asked to provide identifying information about the elder in question. This includes name, age, location, and information about the elder’s functioning and limitations. The reporter will be asked the nature of the allegation(s). The basis for the allegation and under what circumstances the reporter came to have information or evidence suggesting that the elder has been abused. The screener should attempt to assess the credibility of the reporter and the information provided. The screener should also assess the presence or absence of a pattern of signs and symptoms commonly associated with elder maltreatment. The presence of these indicators is reason to investigate, but does not prove that abuse has occurred since other factors may account for these symptoms (Ramsey-Klawsnik, 1993). The report is screened in and a formal investigation commences if: the referred individual meets eligibility criteria (for age, geographical location, etc.), indicators of maltreatment are reported, the reporter appears credible, and the information appears reliable. Reports made by professionals mandated to report suspicions of abuse are typically screened in. Sometimes the reporter does not appear credible, provides questionable information, or provides insufficient information to convey the possibility that an elder has been abused. These cases, and those in which the referred individual does not meet eligibility criteria, will be screened out and the investigatory process terminated in most jurisdictions.
Steps of an elder protective service investigation
- Intake and screen referral
- Gather background data
- Interview the referral source
- Review appropriate records
- Interview collaterals
- Interview informants
- Interview family members
- Interview suspected victim
- Interview suspected offender(s)
- Arrange specialized diagnostic evaluations.
- Document findings in official report
- Make substantiation decision
Urgency of Response
Most protective service systems have standards regulating how quickly an investigation must commence following the screening in of a report. Urgency is often stressed, particularly in those situations deemed as potential “emergencies.” An emergency situation is one in which the physical safety of an elder is in danger, and protective services are immediately needed to prevent serious harm from occurring. In these situations, an immediate response in the form of a face-to-face contact with the elder should occur.
ILLUSTRATIVE CASE: A woman called adult protective services reporting that she has just been contacted by her elderly neighbor, Mrs. M… who resided with her adult son. The reporter stated that she had learned from Mrs. M. that her son had been drinking and earlier in the day had struck her about the face and arms when she refused to give him her social security check. The reporter stated that Mrs. M. made the call while the son left the premises to cash the check and purchase more beer. Mrs. M. had communicated her fear that her son would again assault her and sought assistance from her neighbor. The reporter stated that the son had recently been released from prison.
In this and many emergency situations, a joint home visit by a protective service worker and a law enforcement officer is indicated. The visit should be made immediately to assess the woman’s safety and deliver necessary intervention.
A non-emergency situation is one in which it is suspected that an elder has experienced abuse but is not in present danger.
ILLUSTRATIVE CASE: During a hospital stay for treatment of a medical problem, an eighty-three year old woman confided in her nurse that her son-in-law had been attempting to have sex with her. The patient explained that her son-in-law had repeatedly opened his pants in her presence to expose his penis and made suggestive remarks. She feared being alone with him and reported that he was showing up at her apartment by himself with increasing frequency. The woman was scheduled to remain in the hospital for the next few days. It was thought that there was no immediate risk of re-offense. In the event the son-in-law came to the hospital, the woman could call upon hospital staff and security to protect her from unwanted contact with him. This allegation warranted careful investigation, and, if substantiated, service delivery. It did not warrant an emergency visit by an investigating social worker. Instead, the social worker visited the woman the next business day, after taking time to gather background information and interview the reporter.
In non-emergency situations, haste in the form of an immediate response can lead to an improperly conducted and ineffective investigation. While it is desirable (even in non-emergency situations) that the investigation commence quickly, this does not necessarily mean that the suspected victim or offender should be interviewed immediately. The “heart” or most important part of the investigation is the suspected victim interview. Because the suspected victim interview is so important, it is critical to conduct it as effectively as possible. Adequate background information can greatly enhance the investigator’s capacity to plan and conduct the suspected victim and perpetrator interviews. The more the investigator knows about the suspected victim, the suspected perpetrator, and the allegation, the better equipped that investigator will be to conduct informed, skillful interviews. Protective investigators are often overworked and carry many cases. This situation creates the temptation to conduct interviews hastily, without first gathering adequate background information and strategizing on the most effective investigation plan.
State regulations governing the conduct of elder protective service investigations differ widely. In all states the informed consent of an elder (or that person’s legally appointed guardian) is required for service-delivery following substantiation of maltreatment allegations. However, in most states informed consent of the suspected victim is not required to conduct the investigation. This enables investigators to contact key collaterals to obtain necessary background information prior to meeting with the referred individual. In some states, such as Illinois, no background-gathering collateral interviews can take place without the informed consent of the suspected victim. APS investigators must be cognizant of the regulations operating within their jurisdictions and conduct all investigations in a legally sound manner in accordance with state laws and regulations. State laws differ concerning the process through which investigators access confidential information from collaterals. Many states require professional service providers (such as physicians) to release confidential information about suspected victims and perpetrators without their informed consent for the purpose of abuse investigation. In other states, investigators must obtain the written, informed consent of the service recipient to access confidential data.
Gathering Background Data
The amount of information and degree of detail which will be obtained will vary, depending upon a number of factors, including the amount of information available from sources such as existing records and collaterals.
Interviewing the Referral Source
An important source of background data is the reporter. The investigator should contact this individual to obtain data directly rather than merely rely upon that information that was gathered over the telephone by the screener during intake and subsequently relayed to the investigator. The reporter may have more detailed information than the screener gathered. Sometimes accuracy is lost in the transmission. Directly interviewing the reporter is especially important when that reporter is a service provider who has extensive information about the elder and the allegation. An additional benefit to the investigator contacting the reporter is that it communicates to the reporter that the allegations are receiving careful assessment.
Reviewing Relevant Records
Data that may help in establishing the allegation’s credibility or lack thereof is frequently found by reviewing existing records. These may include previous protective service records, medical or mental health records, and central registries of known offenders, and existing criminal records on the suspected offender.
Collaterals are professionals and paraprofessionals currently or previously involved in service-provision to the suspected victim, that person’s family, and/or the suspected offender. Collaterals are often an important source of information which enables the investigator to understand the life situation of the referred elder. They may provide medical diagnoses and prescribed treatments and medications, information about that individual’s physical and mental health, level of functioning, barriers to communication, etc. Collaterals may have information about the quality of the relationship between the suspected victim and perpetrator.
Collaterals may or may not have information concerning the alleged abuse. If they lack first-hand information about possible maltreatment, they may nonetheless have opinions as to the likelihood that the elder has been abused. These opinions may or may not be helpful to the investigator, depending upon their basis. Investigators should accept these as opinions, rather than as statements of fact or proof that abuse did or did not occur. Many professionals who are well-educated about medical, mental health or other issues may be untrained and inexperienced in dealing with elder abuse. Opinions based upon ignorance and false assumptions are not helpful in establishing the validity of an allegation.
ILLUSTRATIVE CASE: Mrs. G is a seventy-nine year old woman who was referred to adult protective services by relatives due to their concerns that Mrs. G’s fifty-two year old daughter was sexually abusing her. When Mrs. G’s visiting nurse was interviewed, she expressed her strong conviction that this allegation was not true. The investigator questioned the nurse in an attempt to determine what facts, observations, and perceptions formed the basis of the opinion. It became clear that the nurse’s opinion was based upon the fact that during five thirty-minute home visits, she never observed the daughter abuse Mrs. G. The nurse’s opinion was further based upon her ignorance about the existence of elder sexual abuse and her disbelief that women are capable of sexually abusive acts. Sexual abuse was eventually substantiated when Mrs. G disclosed to the investigator that frequently her mentally ill daughter crawled into bed with her at night and molested her breasts and genitals. Several other female members of the extended family also reported that they had been sexually abused by this individual during their childhoods.
In some cases, collaterals have first-hand information about alleged maltreatment. This information is crucial to the investigation, and the collateral serves as an informant.
An informant is an individual alleging abuse. An informant may be the reporter, a collateral service-provider, a family member, or concerned other. Informants may have witnessed maltreatment or observed evidence of it. Individuals who have received a disclosure of abuse from an elder are also informants. Still another category of informants are other victims of the suspected perpetrator. This type of informant may be found especially in institutional cases in which a staff member, resident, or visitor has assaulted more than one individual.
Generally, it is advisable to interview informants prior to the suspected victim interview as a method of gathering evidence and understanding the allegation as completely as possible. The information they provide can help the investigator prepare to interview the suspected victim. This is particularly important if the suspected victim has difficulty communicating.
ILLUSTRATIVE CASE: Mr. T. is an eighty-one year old man suffering from Parkinson’s disease. He is blind, hearing impaired and communicates primarily through grunting. He resides in a nursing home and is totally dependent upon others for personal care. His seventy-nine year old wife visited him early one morning. As Mrs. T. entered her husband’s room, she observed a male orderly twist her husband’s arm behind his back while Mr. T winced with pain. Shocked, she backed out of the room, returned home and telephoned the police. The police summoned adult protective services and a joint investigation ensued. The interview with the wife-witness formed the basis of the investigation. Due to his impairments, Mr. T. was unable to explain what had occurred, but did grunt his affirmation when asked if the orderly had hurt him.
Informants should be asked to provide the information that they have about the suspected abuse as fully and accurately as possible. They should also be asked to discuss the mechanism through which they gained this information.
Investigators should attempt to gather the following information in preparation for the suspected victim interview.
Interviewing Family Members
Family members who are acting in the elder’s best interest can often provide useful background information (Table 3). Like collaterals, family members who are not informants may help the investigator understand the life circumstances of the suspected victim. They may have opinions about the possibility that their elderly relative has been abused, and these opinions may or may not be helpful to investigatory efforts, depending upon their basis. Family members who are not acting in the elder’s best interest may have a vested interest in proving or disproving that abuse has occurred, regardless of the truth. If they have abused or neglected the elder or collaborated with an offender, they may purposely withhold important information. Investigators must therefore use careful judgment in deciding which family members to interview, how to schedule interviews (before or after the suspected victim interview), and how much information to reveal during these interviews. It is vitally important to refrain from endangering an elder by sharing information with an abusive family member (or one in collaboration with an abuser) or by sharing that information in a poorly timed fashion.
ILLUSTRATIVE CASE: A report of suspected abuse was received by protective services regarding Mrs. Z, a seventy- five year old woman recovering from a broken hip. The referral source was the home health aide agency providing aides on a daily basis to bathe, dress, and otherwise assist Mrs. Z. Aides had observed that Mr. Z behaved in a very controlling manner towards his wife. He was insistent that he would personally bathe and dress her. He laid her naked upon her bed to bathe her and physically restrained her by tying her with belts and other devices. As Mr. Z prepared to bathe his wife, aides observed Mrs. Z resist, scream, and exhibit fear of her husband. They had not observed the actual bathing as Mr. Z would banish them from the room. The bathing lasted for long periods of time, during which Mrs. Z cried and screamed.
Protective services staff realized that to telephone Mr. Z and inform him of the allegation before interviewing Mrs. Z might endanger her safety. Alerting Mr. Z to the allegation might cause him to intimidate his wife into lack of cooperation with the investigation. Staff understood that it would be extremely important to arrange safety and privacy from her husband in order to effectively interview Mrs. Z.
Background information to gather
- Information about the elder
- Identifying information:
- With whom the individual resides
- Level of functioning:
- Physical and mental health status
- Level of independence/dependence
- Apparatus/equipment necessary to function
- Types of personal care necessary
- Capacity for and style of communication:
- Primary language or form of communication utilized
- Level of speech and language
- Barriers to effective communication
- Communications aids utilized
- Services presently received:
- Location of service provision
- Significant others:
- Nuclear Family members
- Extended family members
- Other significant people (friends, neighbors)
- Types and level of care which others provide in situation about the allegation
- Identifying information:
- What specifically is alleged?
- By whom?
- What, if any, evidence exists to support this allegation?
- Has the elder made a disclosure of abuse?
- If so, to who was the disclosure made?
- Under what condition was this statement made?
- What, if any, details were provided?
- Were any previous allegations of maltreatment made?
- If so, were they substantiated?
- Have any previous investigative interviews occurred?
- If so, what were the results?
- Information about the suspected offender
- Identifying Information:
- With whom the individual resides
- Relationship to the suspected victim
- Mental and physical functioning
- Any previous abuse allegations against this person?
- Identifying Information:
Interviewing Suspected Victims
Good investigatory interviewers are truly interested in the suspected victim’s well-being and are perceptive of and respectful towards that individual’s needs, fears, worries, and position of powerlessness in relation to any offenders. Noted trauma specialist, Dr. Judith Lewis Herman writes, “Trauma robs the victim of a sense of power and control; the guiding principle of recovery is to restore power and control to the survivor” (Herman, 1992). A good interviewer communicates respect and caring and makes the interview an empowering, rather than a victimizing, experience. In addition, good interviewers need (1) an understanding of the clinical dynamics of victimization and trauma, (2) training regarding investigatory methods and techniques, and (3) knowledge about the normal aging process and the needs of older individuals.
A number of steps can and should be taken to make the investigative interview an empowering rather than a victimizing experience for the elder. Guidelines for interviewing suspected victims of elder sexual abuse are provided by Ramsey-Klawsnik (1993). Certain of those are applicable to investigative interviews designed to assess for other types of maltreatment. One such important guideline is to interview the suspected victim privately, unless that person requests the presence of a trusted support person. Outnumbering an individual with multiple interviewers can be intimidating and inhibit dis closure. In some jurisdictions protective services workers and law enforcement officers jointly investigate allegations of serious crimes against elders. This collaboration is often very appropriate and effective; however, only one individual should interview the suspected victim, rather than both a social worker and a police officer.
Assure privacy for the elder by careful attention to the location and timing of the interview. It is particularly important to assure privacy from the suspected offender and others who may be pressing the elder into making particular statements. If the suspected offender resides with the elder, interviewing away from the elder’s residence is suggested. Some elders attend adult day care or other out-of-home services and can be effectively interviewed on those premises that provide privacy and safety from the suspected perpetrator. It may be necessary to interview impaired elders for whom travel is difficult in their home. If assault occurred at that location, the victim may not feel safe there. When interviewing at the site of the suspected abuse, it is important to take steps to ensure the victim’s sense of safety, or disclosure is unlikely. For example, collaterals may be able to provide the suspected perpetrator’s schedule, in which case the interview can occur when that individual is away from the premises.
Investigators should inform elders about their identity, affiliation, and role. It is important to be honest but not overwhelming. It is important to recognize the fear and discomfort that elder victims of maltreatment often experience during investigative interviewing. They may fear the investigator, the perpetrator, or that intrusive and unwanted services may be forced upon them. Rapport-building prior to asking questions about possible victimization is a necessary but not sufficient step to reduce this discomfort.
The interpersonal behavior displayed by the interviewer is critically important. Interviewers must maintain appropriate social boundaries and refrain from acting in a physically intrusive manner. The investigator should refrain from taking notes during early portions of the interview because it is intimidating and interferes with building and maintaining rapport. If appropriate, notes can be taken during the latter portion of the interview when the elder is more comfortable. The best approach is to write detailed notes immediately following the completion of the interview.
Following friendly communication during rapport-building, the investigator may then ask focused questions designed to assess relationships with caregivers, screen for maltreatment, and evaluate the allegations. These questions should begin with general questions and move slowly and gradually to more specific questions. Examples of general questions include: How are you feeling? How do you like living here? What is your typical day like? For individuals in residential placements questions include: How are you treated by the staff? For those residing with family members: How do you get along with your spouse, son, daughter, etc.? Any responses that seemed potentially linked to abuse experiences should be explored. For example, an individual resides with her nephew and reports that she does not get along well with him and finds his behavior disturbing; an inquiry as to why this is needs to be made. Perhaps the client responds that her nephew is ornery and mean, especially when he has been drinking. Further exploration is then in order. The investigator might ask, “What does your nephew do that’s mean?” to which a disclosure of maltreatment may be offered.
If general questions fail to result in a disclosure or discussion of the allegations, the investigator must become more direct in posing questions. Ways to do this include asking about the referral information, including any reported signs or symptoms of maltreatment. Another method is to more fully explain the job of the protective service investigator as one who talks to people to inquire if they are safe and well-cared for. The investigator might also define and explain the major types of elder maltreatment in terms easily comprehended and inquire if any of these have occurred. Investigative interviewing is an interactive process in which the specific question posed will be formulated in response to information previously provided by the interviewee. Case specifics, including the allegations, will also inform the selection and sequencing of questions.
ILLUSTRATIVE CASE: Mr. P, an eighty-two year old double amputee, was referred to APS by a neighbor from an adjacent apartment: Mr. P’s thirty year old grandson resided with him and was responsible for his care. The reporter stated that the grandson was unemployed and appeared to be living off of Mr. P’s assets, including his monthly social security and retirement checks. The reporter was concerned because the grandson spent significant amounts of time away from the apartment, including many nights when he stayed with his girlfriend across town. During the grandson’s absence, no one appeared to be caring for Mr. P. The reporter knew that Mr. P needed assistance transferring from bed to wheelchair as well as with toileting, bathing, and dressing. He was also unable to prepare meats independently. She feared that he was in danger when left alone for long periods of time.
During the suspected victim interview, the investigator shared information about himself and his role, built rapport, and then asked general questions about Mr. P’s life, needs for assistance, and relationship with his grandson. Although he appeared weak, unkempt, and ill, Mr. P reported that he was fine. He stated that he needed help with some things, but that was the purpose of “hiring” his grandson to reside with him. The investigator inquired about the “hiring” arrangement, and Mr. P reported that it was only fair that his grandson receive compensation for his work. Mr. P indicated no problems with this arrangement.
After general questioning failed to produce a disclosure, the investigator escalated the questioning to a more direct level, asking if the grandson actually slept every night in Mr. P’s home. Mr. P reported that he did not. Continued questioning revealed that at times Mr. P was left alone for two to three days at a time, stranded in bed without access to food, water, medicine, toileting, or bathing assistance. Mr. P was asked if he would consent to a medical examination to assess his physical condition. He did and was found to require hospitalization for malnourishment, dehydration, and urine burns on his thighs, groin, buttocks, and stomach. Upon hospital discharge. Mr. P accepted placement in a licensed adult foster care borne.
In some jurisdictions, investigators are instructed to undertake a visual inspection of the suspected victim’s body to assess for injuries and other medical problems. Elders are informed of this practice during the interview and are asked to disrobe to allow the inspection. This author feels strongly that this is an improper practice, for two important reasons. Most APS investigators are social workers with no medical or nursing training or credentials. They are therefore not qualified to assess injuries or other medical conditions. In addition, this practice is very demeaning and humiliating for the suspected victim. Protective service clients have expressed being strongly upset at this violation, particularly female clients who have been subjected to visual inspection by male investigators. An argument can be made that this is an unethical procedure for both reasons. A much better practice is for the investigator to visually observe any body areas not covered by clothing during the interview (such as face, hands, arms) and to ask the elder if s/he experiences any pain, injuries, physical discomfort, or untreated medical problems. If the elder acknowledges any of these or appears to be in a weakened or ill condition, the elder should be asked if s/he would consent to a medical examination to assess health problems. Proper physical examination by a qualified health care practitioner can then be arranged in an appropriate setting. Any medical problems caused by maltreatment can then be documented and treated by licensed medical practitioners who can also attest to the injuries as medical experts, should the need arise.
Interviewing Elders with Communication Problems
Suggestions for interviewing cognitively alert elders who suffer speech and language impairments are provided by Ramsey-Klawsnik (1993). Techniques that may be employed include yes/no questions to which the elder nods, points, or otherwise non-verbally responds. Anatomical dolls can be offered to enable the victim of physical or sexual assault to point to the parts of his/her body that was injured and to the part(s) of the offender’s body which was used to inflict injury. The victim can also be asked to position dolls representing the self and the offender to demonstrate what occurred. Alternatively, victims can be asked to make elder anatomical drawings (Groth, 1990) to indicate how and where they were injured or assaulted. Anatomical drawings and dolls can also be utilized with elders who can speak but are uncomfortable using words to describe their assault.
Interviewing Elders Suffering Mental Confusion
Eliciting valid and reliable information from suspected victims who experience mental confusion presents special challenges to investigators. Information provided by collaterals prior to the victim interview and first-hand interaction with the elder during the rapport-building phase of the victim interview provide opportunities for the investigator to assess the individual’s capacity to provide meaningful information. Some older individuals suffer short-term memory loss and other cognitive impairments, yet are able to accurately recall and relate victimization experience. Mental or physical illness which results in significant mental confusion, such as advanced Alzheimer’s disease, may render elders unable to provide clear, responsive answers to interview questions. These individuals may not be able to reveal through verbal or non-verbal means the conditions of their treatment by various care providers. Often, it is impossible to adequately investigate and make informed substantiation decisions in the absence of reliable and valid results from a suspected victim interview. As a result, abuse of seriously mentally impaired elders may go undetected and untreated. In the event that abuse has been witnessed or convincing medical or other evidence of abuse is collected, the allegations may be substantiated. When an investigator is in doubt as to the credibility of a disclosure due to cognitive impairment of the elder, expert consultation should be sought in the form of a specialized diagnostic evaluation (to be discussed below).
Interviewing Suspected Offenders
Elder abusers can be broadly categorized into two groups (Table 4). “Type I” are those without abusive, sadistic, or criminal intent who engage in maltreatment due to ignorance, incompetence, being overwhelmed, or lack of adequate resources. “Type II” are those with abusive or sadistic personalities who intentionally inflict pain and suffering and may use the elder and that person’s assets in deliberate and extensive ways. Offenders of this type may sexually abuse, seriously physically and psychologically abuse, and/or commit significant acts of financial exploitation.
Well-intentioned, overwhelmed caregivers who lash out in anger or engage in neglectful action due to exhaustion or lack of resources may experience guilt and shame regarding their abusive actions. They may admit the maltreatment and be receptive to intervention designed to increase their capacity to provide non-abusive caregiving. Offenders who are basically incompetent to provide care due to their own physical or mental impairments may not comprehend the abusive or neglectful quality of their actions. These “Type 1” abusers are generally not at high risk to become violent during the investigation. Criminal investigation and prosecution are not seen as necessary or helpful for reasons cited by Formby (1992).
“Type II” offenders pose very different problems for their victims and for interventionists, as well as for society at-large. Heisler (1991) points out the compelling reasons for involving the criminal justice system in the serious crimes of these offenders. Under the pressure of an investigation, which could possibly lead to criminal charges, such an offender has a strong vested interest in disproving the allegations. The victim’s safety may be further compromised, in that the offender may have strong motivation to intimidate the victim to prevent disclosure. Unfortunately, in many maltreatment cases, an informed judgment cannot be made until the completion of the investigation as to whether the offender is of the first or second type. Safety concerns therefore demand careful, informed decision-making around arranging and conducting the suspected perpetrator interview.
The following guidelines are offered, and are especially relevant in cases involving “Type II” offenders. The use of good judgment in determining when to notify the suspected offender of the allegations, how to accomplish this, and when and where to conduct the suspected perpetrator interview is imperative. A general rule of thumb is to avoid notifying the suspected perpetrator of the investigation until the suspected victim has been interviewed. If the suspected offender has access to the elder, prior notification may result in violence or intimidation designed to prohibit disclosure.
|Type I||Type II|
|Lack abusive, sadistic, or criminal intent||Have abusive or sadistic personalities and oftentimes criminal intent|
|Well-intentioned, competent caregivers lash out or neglect when overwhelmed by great stress OR well-intentioned, incompetent caregivers abuse/neglect due to their own impairments, ignorance, or lack of resources||Abusers purposefully inflict pain and suffering; may use the vulnerable adult and that person’s assets in deliberate and extensive ways.|
|Abusers face investigative interviews feeling defensive and upset but rarely retaliate against vulnerable adults||Abusers face investigations with the aim of getting rid of the investigator and preventing further access to the victim and service providers. Abusers may intimidate or harm the victim to prevent disclosures during investigations|
|Abusers often experience guilt and shame regarding their harmful action OR may fail to realize the harmful nature of the maltreatment due to their own incompetence||Abusers are motivated to protect themselves from consequences for their abusive actions. They often lack guilt, shame, or remorse regarding the harm they have inflicted on their victims.|
|Abusers often acknowledge their abusive/neglectful actions||Abusers often adamantly deny the allegations, may express outrage and hostility that they have been accused|
|Abusers likely to accept service to relieve the caregiving burden or to improve the quality of life for their victim and for themselves.||Abusers are unlikely to cooperate with service-provision to themselves or their victims, they view service as an intrusion and regard in-home helpers as potential witnesses.|
|Ideal intervention: Provide services, referral to law enforcement not necessary or helpful||Ideal intervention: Protect the victim from the offender, referral to law enforcement is recommended.|
Even following the victim interview, it is generally inappropriate to notify the suspected perpetrator of allegations of serious crime while this person continues in a position of power and control over the suspected victim. Policy and practice should be designed with these concerns in mind.
The investigator should schedule the suspected offender interview at a time and place that does not endanger the elder, particularly if physical or sexual assault is alleged. Some offenders may become violent after learning of the allegations. This violence may be directed at their elderly victim, if steps are not taken to prevent this. Violence could also potentially be directed at the interviewer. Individuals with histories of interpersonal violence, substance abuse or mental illness should be interviewed in an office, where the investigator is not alone and can arrange the interview with safety concerns in mind. It is often wise to involve law enforcement personnel in these interviews, to protect everyone’s safety. Investigative collaboration between law enforcement authorities and APS should routinely occur when serious crime is alleged. It is strongly recommended that law enforcement agencies and APS systems develop protocols in advance for collaboration in these cases. Suggestions for collaboration are provided by Heisler (1991). In cases of alleged sexual abuse, serious physical abuse, and significant financial exploitation, it is often preferable that a law enforcement officer rather than a protective service social worker conduct the suspected offender interview.
The suspected perpetrator should be interviewed after conducting the suspected victim interview. An important aspect of the perpetrator interview is confronting the suspect with any disclosures made by the victim. To this end the investigator should begin the interview with general questions designed to elicit personal information to assess that person’s general functioning and history and move next to open-ended questions about the elder. Examples of such questions are: “Tell me about your mother; what kind of woman is she?” “What has it been like for you living with your mother and caring for her for the past two years?” “What kinds of problems have you experienced in caring for your mother?” “How do you deal with those problems?”
Any responses that seem potentially indicative of maltreatment should be explored. For example, if a woman responded that taking care of her mother has been very difficult because the mother wanders about the neighborhood when left alone, a question about what measures the daughter has taken to deal with this problem should be included. During one such interview, a woman reported that she had resorted to overmedicating her mother and tying her to her bed and chair, both at night and during the day.
It is important to respond non-judgmentally to answers and continue probing. Responding with criticism or educating the caregiver as to why the behavior is inappropriate may cause a defensive reaction that result in no further data being revealed. At the completion of investigation, education and intervention measures to prevent further maltreatment can commence.
After exploring the suspected offender’s relationship to the elder with open-ended questions, the discussion can move to the allegations and any disclosures made by the victim, asking the suspected offender to respond to the allegations. Unlike “Type I” offenders, perpetrators of serious abuse towards dependent others do not often confess.
Specialized Diagnostic Evaluations
In some cases, one or more specialized diagnostic evaluations can be useful during the investigative process. These may include a comprehensive medical examination or a specific type of diagnostic medical procedure, such as a rape kit exam when recent sexual assault is suspected. Chelucci and Coyle (undated) provide guidelines for medical examination and documentation of injuries caused by maltreatment. Forensic dental assessment may help to confirm the offender’s identity in cases in which the victim suffered human bite marks. In certain situations, psychological testing of either the suspected victim or suspected perpetrator can aid in establishing the validity of allegations. Neuropsychological testing may be forensically valuable in assessing disclosures made by individuals with memory impairments. Specialized mental health evaluations are also sometimes helpful. For example, a suspected sexual offender evaluation may prove useful in cases of alleged elder sexual abuse. Such an evaluation will not prove or disprove that a suspect committed a sexual offense against a particular individual but it may help to determine if that suspect has a psychological profile and personality that is consistent or inconsistent with the allegations (Salter, 1988). Forensic assessments performed by mental health clinicians trained to evaluate suspected abuse victims may also help clarify the nature, extent, and impact of any maltreatment.
Specialized diagnostic evaluations can be extremely useful in assessing allegations and documenting maltreatment. In addition, many times they constitute the best method for assessing the impact of the maltreatment on the victim’s functioning so that necessary intervention can be planned. Investigators servicing urban areas are likely to have access to the specialized services and should utilize them when indicated. Unfortunately, these specialized services are often not readily available in rural areas. Telephone consultation with appropriate experts may prove useful in some cases.
Accurate, clear, and immediate documentation of all activities and findings is critical during a protective service investigation. Precise notes are often crucial to valid fact-finding. Documentation should take place throughout the entire course of the investigation, commencing with case intake and ending with the written, final investigation report. The process of documentation is central to the decision-making process regarding the question of substantiation. Documentation is the process of committing to writing the evidence upon which the decision is based. In addition, the process of analyzing the available information which occurs during documentation helps the investigator to carefully study the findings and arrive at a substantiation decision. Adequate documentation helps social workers to assess and understand the maltreated elder’s needs and, in this way, informs intervention planning and service delivery.
The written documentation should indicate what records have been reviewed as part of the investigation and what information has been obtained from those records. It is important to identify all sources of information. Writing clearly, avoiding the use of confusing pronouns, and being clear about time frames are important considerations. Missing information should be noted, along with the reason for this. For example, “The investigator was unable to interview the referral source due to the fact that the report was filed anonymously.”
Detailed notes should be taken during interviews of reporters, collaterals and informants documenting the full name, credentials, position, and affiliation of any service providers interviewed and the source of that person’s information about the suspected victim. The date, length of time, and type of interview (face-to-face, telephone. etc.) should be noted. For example, “The investigator interviewed Mrs. X.’s physician, Dr. A., for thirty minutes on 4/11/94 in Dr. A.’s office.” Opinions must be carefully separated from facts. For example. “Dr. A. examined Mrs. X. on 4/09/94 and observed bruising on her neck,” is a fact. “The physician felt that the bruising was not caused in the manner described by Mrs. X’s son,” is an opinion. Expert interpretations and opinions about the facts are very important and should be carefully documented in the investigator’s report. It is also important to include the basis for these opinions.
It may not be possible to take notes during interviews of family members, the suspected victim, and the suspected perpetrator because note-taking interferes with building and maintaining adequate rapport and inhibits disclosures and admissions. When comprehensive notes have not been written during the actual interview, they must be taken as soon as the interview is concluded. Busy investigators may be tempted to drive back to their offices or undertake other activities immediately following an interview, deferring note writing until the end of the business day or even several days later. This is extremely poor practice, as waiting even several hours can cause facts to become blurred and memories to become clouded.
In all cases, it is important to note date, time, length, and location of interviews and the identity of those present; document interview questions posed arid responses provided, particularly questions designed to screen for maltreatment; and provide key quotes from interviews, especially those in which maltreatment has been disclosed or denied.
During an investigative interview, what is observed is as important as what is heard, noting the appearance, behavior, affect, and demeanor of those interviewed. Documenting the condition of the elderly individual’s surroundings, particularly in cases of alleged neglect is necessary. It is important to be descriptive. For example, reporting, “The home was in deplorable condition” is far less useful than describing. “The home consisted of three rooms, one of which was filled with garbage and broken furniture such that walking through it was impossible. The elder’s room contained two broken windows. The bedding was visibly quite soiled and smelled of urine.” Documentation of any non-verbal findings, such as X-rays depicting a broken bone or anatomical drawings marked by the victim to indicate the site of inflicted injury, should be included.
Investigatory conclusions and the basis for these must be stated. If information has been gathered that does not support the conclusions, that information must be cited with an explanation of the reason the conclusions were reached despite certain contradictory findings. For example, an illustrative case was cited earlier in which a nursing home orderly was allegedly observed twisting the arm of a patient. During the suspected perpetrator interview, the orderly adamantly denied this allegation, stating his explanation that the patient’s wife was a trouble-maker who had wanted him fired for some time. The investigator concluded in his report. “It is my finding that Orderly N. physically abused Mr. T. by twisting his arm behind his back. This conclusion is reached despite Orderly N.’s strong denial of the allegation, based upon the following evidence:
Mrs. T.’s observation of and credible description of the episode; when questioned during the suspected victim interview, Mr. T. nodded and grunted acknowledgement that he had been harmed by Orderly N.; and bruising about Mr. T.’s wrist documented by Dr. S. It is Dr. S.’s opinion that the bruises resemble finger imprints.” The investigator might further explain his conclusions by stating that Orderly N. has motivation to lie, in that substantiation of the allegations may well result in his discharge from his job and his name being placed on the state’s central registry of elder abusers.
All documentation must be sufficiently clear to allow a person uninvolved in the investigation (such as a case reviewer) to gain from the report a full understanding of the allegations, the process and methods utilized to conduct the investigation, the substantiation decision which was made, and the basis for that decision. In the event that civil or criminal court action is initiated or the investigation results become subject to scrutiny for other reasons (the perpetrator officially contests his name being placed on the central registry of elder abusers, for example), proper documentation will protect the best interests of the elderly victim, the investigator, and the agency responsible for the investigation. Proper documentation also protects the interest of an individual falsely accused of maltreatment.
Deciding If Abuse Has Occurred
There is no magic formula for deciding if maltreatment allegations are valid. Investigative decision-making is often best accomplished with supervisory input (two heads usually are better than one when important decisions need to be made). The process of a carefully planned and executed investigation and documentation of all findings typically results in conclusions becoming evident. The investigative process is much like putting together a jigsaw puzzle: any one or a few pieces by themselves do not reveal the entire picture, but many pieces carefully fit together begin to cause the over-all picture to emerge.
An admission from the suspected perpetrator should not be viewed as necessary in order to substantiate an allegation. As previously discussed, offenders with abusive or sadistic personalities who enjoy exploiting less powerful others are unlikely to confess, particularly if criminal prosecution may result. In cases in which APS and law enforcement collaborate on an investigation, differing outcomes may occur in each system. That is, APS investigators may have sufficient evidence to substantiate abuse allegations, even if the criminal justice system does not initiate prosecution. The goal of the APS system is protection of vulnerable, maltreated individuals, and this goal is quite different from that of the criminal justice system.
A thorough, carefully conducted investigation enables staff to make sound substantiation decisions and to assess the impact of any maltreatment on the involved elder’s functioning. This information is necessary to plan services designed to prevent further abuse and facilitate recovery from maltreatment which has occurred. The required intervention will be related to the victim’s needs, wishes and resources, the type of offender, the nature and extent of maltreatment, the victim’s relationship to the offender, and agency and common resources.
- This and other illustrative cases are composites based upon elder maltreatment cases referred to the author for clinical consultation. Identifying information has been changed to protect the confidentiality of the victims.
- An exception to this arises when the abuse of an elder who cannot speak or otherwise communicate has been witnessed by another. In this case, the interview of the eyewitness becomes the central piece, or ‘heart,” of the investigation.
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