;E 3 80223 A No -LONGER ‘ PROPERTY 1 P 0 U N . 1.1 B RA RY wwrmgmn Ufiivérsity L5: ($3/Z5 ‘x, __ 1 R N {J ‘*2 '‘‘;‘.“£l Q5-"‘5;‘; 1‘ E ‘L: ‘a:’o.‘.':<:3 VJ 1 ~ ., ;: 1.‘ ; -= s._ ;¢;.¢,‘:;. ‘,_;3"';".'_\v'_"_fi“ . E - - L‘ M1111 Bnef N0v171989 Lfiafixsgazas i..~‘0U§s, Ma. V“... ‘W. ‘i ( ‘ - CONGRESSIONAL RESEARCH SERVICE 33333;»; S 2 IIIIIIfi I @ifl[Ei@fiimml A DOHESTIC VIOLENCE: ELDER ABUSE MINI BRIEF NUMBER MB80223 AUTHOR: Fowler, Jan Education and Public Welfare Division THE LIBRARY OF CONGRESS CONGRESSIONAL RESEARCH SERVICE MAJOR ISSUES SYSTEM DATE ORIGINATED Q§4Q§1§Q A DATE UPDATED gggggzgg FOR ADDITIONAL INFORMATION CALL 287-5700 0925 CRS- 1 HB80223 UPDATE-09/25/80 E§.L3.E_2§.Fl.I.1.'.“+’..'-Y.-’.3;9..1l Abuse, neglect, and exploitation of the elderly by family members is beginning to receive public attention. While few systematic studies of elder abuse exist, there are numerous anecdotal reports of beatings, forced confinement, verbal assaults and threats, withholding of food and medicine, stealing money or property, and defrauding of cash benefits. Much abuse of this nature allegedly takes place in private homes and is perpetrated by the victim's children, grandchildren, or other relatives. There are also accounts of abuse occuring in institutions, particularly in nursing homes. Although only 5% of the elderly reside in institutions, institutional abuse has in the past been the subject of numerous investigations and congressional hearings. while abuse in institutions is still acknowledged to be a problem, this paper focuses on elder abuse in the home, which has been receiving increasing scrutiny by Congress. In recent months, Congress has begun to assess the extent and characteristics of elder abuse and to explore what role, if any, the Federal Government should play in alleviating it. vBACKGBOUHD Abuse of the elderly has become increasingly publicized during the last year, and on June 11, 1980, the Senate Special Committee on. Aging and the House Select Committee on Aging held joint hearings on the subject. The committees heard testimony from victims as well as ’researchers, protective service workers, and State and local officials. However, while experts have only recently begun to realize the extent of elder abuse and to consider ways of alleviating it, other patterns of violence in the family have, been known to exist for some years. The first form of family violence to receive national attention was child abuse. During the 19605, the popular and professional media began to publicize the problem; by the end of the decade every State had some kind of child abuse reporting statute. Federal legislation in the 1960s began to target increased funds to child welfare services, including child protection. This primarily took the form of financial assistance to the States under title IV—B of the Social Security Act (child welfare services), and the social services component of title IV-A, which later became title XX (social services), of the Social Security Act. Congress had traditionally been reluctant to intervene directly in family matters, which many felt should be — under State jurisdiction. However, by the early 1970s, in the face of growing public concern, Congress began to hold hearings and consider specific legislation concerning child abuse. On Jan. 31, 197%, the Child Abuse » Prevention and Treatnent Act (P.L. 93-247) was enacted. The Child Abuse Prevention and Treatment Act established the National t nter on Child Abuse and Neglect within the Department of Health, Education and Welfare (now the Department of Health. and Human Services--DHHS) and provided for direct grants and grants to States for projects to prevent and treat child abuse and neglect. When the Act was reauthorized and amended in 1978 (P.L. 95-266), the focus was expanded to include child sexual abuse and CBS- 2 MB80223 UPDATE—09/25/80 sexual exploitation, also the object of increasing public indignation. To qualify for funds under the State grant program, the States must meet certain Federal statutory requirements, including provisions in State law for mandatory reporting of abuse, izsunity from prosecution for those who repo it, and prompt investigation of all reports. In FY80, #6 States and territories qualified for Federal funds under the Act. A growing awareness developed during the 1970s of another form of family violence: spouse abuse. Prompted in part by the women's movement, battered spouses *— primarily women —— began to speak out and to seek treatment and services. Women's .groups and community" organizations, usually relying heavily on volunteers and local support, started to ope shelters, which were often immediately filled to capacity with battered women and their children. Pressure began building for legislation, at both the State and Federal levels, to address the problem. As of June, 1979, 38 States and the District of Columbia had enacted legislation to provide some kind of assistance to domestic violence victims. [NOTE: The term "domestic violence" is used by many to refer primarily to spouse abuse, although Federal legislation has often defined "domestic violence" more broadly, to include elder abuse and tother forms of family violence as well.) These laws range from changes in civil and criminal statutes to appropriations for shelters and other supportive services, and vary widely in emphasis and intent. In the 95th Congress, a bill that would have established a Federal office on domestic ; violence and set up a grant program for shelters and other projects was passed by the Senate but failed to pass the House of Representatives. The 96th Congress has been considering similar" legislation. (See Legislation below.) A few recent surveys of abuse of the elderly in private homes do exist, but as yet it appears to be impossible to arrive at a precise incidence figure. As with child abuse and spouse abuse, any incidence figure for elder abuse is thought to be subject to underreporting. Victims often seem .reluctant to bring their situation to the attention of the authorities, and professionals who might come into contact with instances of abuse —- social service workers, physicians, police offices, attorneys, etc. - may be unable to recognize the symptoms of abuse or uncertain about where and how to report their suspicions. All 50 States have mandatory reporting laws for suspected child abuse and immunity from prosecution for professionals and officials who report it, while only 12 States have similar laws concerning abuse of adults. Recent studies of elder abuse differ from one another in their categorization of types of abuse, but all included a category for physical V abuse (hitting, slapping, burning, etc.) and another for psychological abuse (shouting, threatening, intimidating). Other types of maltreatment assessed by certain studies include isolating, ignoring, .orv confining the victim; withholding food or medicine; extorting money or property; and sexual abuse. some researchers have attempted to distinguish between abuse and neglect while others consider all forms of maltreatment to be abuse. One research approach has been to survey professionals who are likely to encounter cases of abuse.) A 1979 Massachusetts mail survey of social and protective services workers, hospital and legal personnel, police officers, and other professionals resulted in 183 citings of abuse. (O'Ma1ley, Helen, CRS- 3 MB80223 UPDATE-09/25/80 et al. Elder abuse in Massachusetts: a. survey) of professionals and paraprofessionals. June 1, 1979. Reprinted in: 6.3. Congress, House, Select Committee on Aging. Elder abuse: The hidden problem. Comm. Pub. ». 96-220. Washington, U.S. Govt. Print. Off., 1980. pp H7-70). In 52% of these citings, the primary form of was physical and ranged from bruises to major fractures. Verbal harassment was the major form of abuse in 11% of the citings and malnutrition in 9%. I A similar mail survey of professionals in Maryland, also done in 1979, yielded 19 cases; 4 additional cases were reported by an agency and 3 by " elderly individuals, for a total of 26 cases (Block, Marilyn and Jan Sinnott. The battered elder syndrome: an exploratory study. College Park, Md., Center on Aging- University of Maryland. Nov. 1979. 133 pp.). §The social agencies and elderly individuals contacted for this survey had very low response rates, and the investigator did not recommend these two sources for studying abuse.) Bruises and welts were present in 31% of the 26 cases , bone fractures in 8%, verbal assualt in 58%, and misuse of money and property in fl6%. In this analysis, categories of abuse were not mutually exclusive, reflecting the fact that victims often suffer more than one type of abuse. While surveys like these are valuable for gathering descriptive data, they do not reliably indicate the incidence of abuse. In many instances abuse may never become known outside of the household in which it occurs. On the other . hand, surveys of professionals in a certain geographic area may overreport abuse to the extent that the same case is reported by more ythan one respondent. A different approach was taken by researchers in Michigan in a 1979 study ouglass, Richard et al. A study of maltreatment of the elderly and other vulnerable adults. Ann Arbor, Mich., Institute of Gerontology. University of Michigan. February 1980. 197 pp.) They interviewed professionals not about particular cases but in general regarding their perceptions of’ the quality of care of elderly people in the hkne.- Most respondents’ felt that older people's needs were being adequately met; fewer than 10% (22 people) of the 228 people interviewed felt that the needs of elders at home were being met rarely or not at all by their caretakers. when questioned about specific forms of maltreatment, however, 7a of the 228 respondents felt that homebound helderly are frequently or always ignored and isolated by their caretakers, Q6 respondents felt that verbal and emotional abuse occurs frequently or always, and 8 felt that physical abuse occurs frequently or always. one often-cited study performed at the Chronic Illness Center in Cleveland, Ohio, found that 9.6% (39 patients) of the 404 60~and-over patients seen by the Center inwa 1-year period in 1977-78 showed symptoms of : abuse (Lau, Elizabeth and Jordan Kosberg. Abuse of the elderly by informal care providers. Aging. Sept.-Oct., 1979: 11-15). In this study abuse was broken down into physical (experienced by 29 persons); psychological (experienced by 20 persons); material, i.e., theft or misuse property or money (experienced by 21 persons); and violation of rights, i.e., being forced from their residence (experienced by 7 persons). (most patients had experienced more than one kind of abuse.) It should be noted that the Chronic Illness Center's caseload consists n Lnly of seriously ill or disabled individuals and thus is not representative of the over—60 population as a whole. Therefore it is probably not valid to apply the 9.6% abuse rate to the entire senior population. In fact, research indicates that a disproportionate amount of abuse is inflicted on the particular subset.of older persons studied by the CRS— 4 HBBOZZ3 UPDATE-09/25/80 Chronic Illness Center. The profile of an abused elder derived from the studies discussed above is that of a frail woman, 75 or older, with at least one major physical or psychological impairment. The profile of a typical abuser gleaned from these studies is less cle cut. All the data appear to indicate that an abuser is most frequently a son or daughter of the victim, with grandchildren and spouses also cited often. Two of the studies found that abusers were more likely to be women, while a third study found men to be more frequent abusers. One study found most abusers to be midd1e—income while another found that most were lower-income. Two studies indicated that abusers were likely to have financial problems and to abuse alcohol or drugs. In response to the need for more information about the problem, Senator Heinz introduced an amendment to the pending domestic violence legislation which directs the Secretary of DHHS to make a study of elder abuse and report to Congress on the findings. (see Legislation, below.) Qe2§e§-9£-E;éer-Ah2§e As is the case with most social problems, it is difficult to determine the specific cause or causes of elder abuse, particularly with the limited knowledge base that now exists. most experts do appear to believe, however, that a major precipitating factor is family stress. Meeting the daily needs of a frail, dependent elderly relative may be an intolerable burden for family members. The resulting frustration may sometimes be expressed in violent behavior. One study found that the elderly person was a significart source of stress to the family in 63% of the reported abuse cases. 1-; association of abuse with financial. problems and drug and alcohol abuse abuse, as described above, is also indicative of a stressful home situation. In their often well-meaning efforts to keep their aged relative out of a nursing home, families may be taking on too»nuch responsibility. This overtaxing of _a family's resources is sometimes exacerbated by Federal and State Government policies that limit or reduce benefits and services to elderlies people when they live with their families. For example the Federal Supplemental Security Income (SSI) program, authorized under title XVI of the Social Security Act, as amended, provides an minimum income floor to low-income aged, blind, and disabled individuals. However, when an eligible individual is living in the household of another .individual and receiving support or in-kind maintenance from that person, the monthly SSI benefit is reduced by one-third. Another example is the Medicare program, the Federal health insurance program, for people 65 and over, which is authorized under title XVIII of the Social Security Act. This program provides for home health services, but they are contingent on prior hospitalization and the beneficiary's need for skilled nursing care. Thus the ongoing nonmedical care and services that a dependent elderly person often needs to assist him or her to remain at home are frequently not covered by Medicare. The Medicaid program (title XIX of the Social Security Act), a Federal—State matching program that provides medical assistance for certain low—income persons, including the elderly, is structured to extensively subsidize nursing home care but offers less assistance to elderly individua : who remain in their own homes. Services such as homemaker and chore services, adult day care, and adult protective services are provided by the States under the social services CR5’ 5 P1B80223 UPDATE-0 9/25/80 program authorized by title XX of the Social Security Act, as amended. This title provides federally matched funds to the States fcr a wide variety of ‘ social services, including many serivces for the elderly. Eligibility is -mited to SSI and Aid to Families with Dependent Children (AFDC) recipients and individuals and families who have incomes less than 115% of the State's median income, adjusted for family size. This criterion alone excludes many families who, despite their ineligibility, may not be able to afford these services on their own. In addition, each State may set its own maximum eligibility level within the Federal standards. Many States limit some or all title XX-funded services to individuals:and families with incomes less than 80% of the State median income, which excludes still more families from the program. Thus it is often only the veryt low-income elderly and their families who are the najor recipients of title XX services. Another reason for elder abuse is thought by some to be the widespread acceptance of violence in American society, which fosters a climate in which it is acceptable to express frustration and stress in violent ways. Research is beginning to suggest that all forms of familyw violence are prevalent, leading one researcher, Dr. Hurray Straus, to state that the family is "by p far the most physically violent group or institution except for the police or the military during a war." (Quoted in Stencel, Sandra. Violence in the family. Editorial Research Reports, v. 1, Apr. 27, 1979: 308.) Dr.r Straus and his associates recently completed a nationwide survey of violence in the family (Straus, u., Gelles, AR. and Steinmetz, 5. Behind closed doors: Violence in the American family. Garden City, N.Y., Anchor Books, 1980). While spouse abuse and child abuse were theeprimary foci of the study, the researchers discovered that violence between siblings and abuse of parents by their children are also widespread. Among families with children aged 3 to in the home, almost one in five children was found to have assaulted a parent within the last year. Even more significant than the statistics for various forms of family violence is the finding that violence often appears to be a learned behavior and that the practice of settling family disputes violently may be transmitted from generation to generation. The researchers found that only 1 child in Q00 had hit a parent during the last year in cases where the parents had never struck the child. The data show, however, that the more the child has been abused by the parents, the more likely he or she is to respond in kind. Almost one child in two was found to»have assaulted a parent in the last year if the parents had been severely abusive toward the child. This finding suggests that some elder abuse may represent the end of a cycle of violence in the family, in which the elderly person had abused his or her children many years before. Erszsnrinq a.§ Alls!iatin9_Abu§s There appears to be agreement among those familiar with the area of elder ?abuse concerning some general approaches to preventing it. Various changes in State and Federal laws and programs have been suggeted to address the problem. ' Experts almost universally agree that the provision of more social services to families who are caring for an older person is essential. These experts contend that more home health services, personal services such as bathing and dressing the older person, homemaker services, home-delivered meals, adult day care, and respite care (short-term total care), would help cns- 6 F MB80223 upnzm-13-0 9/25/so lessen the family stress that can result from constantly responding to the needs of a dependent family member. One way to help “accomplish this,‘ many feel, is to make changes in those Federal programs, such as SSI,v Medicare, and Medicaid, that currently place limitations on benefits and services tn elderly persons who live at home and are cared for by family members. So. feel that more liberal incoe eligibility levels for title XX services needed by caretaking families would also be helpful. (Without an accompanying tincrease in title XX funding, however, it is debatable how much impact this would have.) Additional Federal policies that encourage and assist families to care for their elderly relatives at home, such as tax credits or T deductions, have also been suggested. As more people live longer, some experts argue that increasing numbers of elderly will be living with their children or other relatives, and this makes it even more important that government policies and programs provide assistance to such families. In the area of State law, the most important change, according to many in the field, would be provisions for mandatory reporting of suspected abuse, prompt investigation by a designated. State agency, and immunity from prosecution for those who report. All 50 States have laws of this type ‘relating to child abuse, but only 12 States have mandatory reporting laws for suspected instances of adult abuse. Other needed changes in State laws, according to those familiar with the area, inlcude more specific tailoring of p civil remedies, such as restraining orders and vacate orders, and social *i services such as emergency shelter, to situations involving sometimes frail, nonambulatory elderly persons living with relatives. Better coordination of State-level programs, including social and protective services, legal aid programs, and senior citizen-oriented programs, is also viewed as important in detecting and intervening in elder abuse cases. . Some advocates of Federal involvement in the area suggest that one way .4 encourage States to make these statutory and administrative changes would be to make Federal funding for elder abuse-related programs contingent on certain State-level requirements. The Child Abuse Prevention and Treatment Act uses this approach in‘ distributing funds to the States for child abuse-related programs, and almost every State has come into compliance with the requirements. The proposed Prevention, Identification, and Treatment of Adult Abuse Act of 1980 uses this method tc>encourage States to modify their adult abuse-related laws and procedures. (See Legislation, below.) At the family level, many advocate family counseling bgfgrg the decision is made to take an elderly relative into the home. Scne families may not * realize the extent of the demands that will be placed on them when they assume the care of a dependent, sometimes impaired, older person. They may need to be educated as to the physical, emotional, and medical needs of older people and what community services might assist them. It may also be necessary to teach all family members how to interact and solve disputes in nonviolent ways. As is the case with most family problems, there is continuing controversy *over whether the Federal Government should get involved in trying to solve the elder abuse problem. some feel that family matters should be under State and local jurisdiction, or that families should be encouraged to solve their own problems without any Government intervention or expenditures. Others W maintain that strong, healthy families are an important national resource a that Government assistance and support should be provided, when necessary, to enable the family to function optimally. Family violence of any kind - parent-to-child, spouseéto-spouse, or CRS- 7 HBSOZZ3 UPDATE“09/25/80 child7to—parent -- seems to be particularly abhorrent to many, and it is likely that public pressure for a Federal solution to these problems will continue. L§§l§LA2lQE POLO HOBO Adoption Assistance and Child Welfare Act of 1980. Makes several amendments to title IX of the Social Security Act (the social services program). Under one of these, the States may now use title XX funds for the provision of emergency shelter for adults as a protective service. (Previously, title XX funds could be used for emergency shelter only for children-): Enacted June 17, 1980. H.R. 191? (G. Miller, et al.)/S. 1843 (Cranston, et al.) Domestic Violence Prevention and Services Act. Provides for the coordination of domestic violence-related activities and the operation of an information clearinghouse within the Department of Health and Human Services (DHHS), and sets up an Interagency Council on Domestic Violence to coordinate programs throughout the Federal Government. Also establishes a State grant program for projects relating to the prevention and treatment of domestic violence, particularly shelters. Provides that, to qualify for funds, States would have to meet certain. requirements, including the designation of a specific State administrative agency, distribution of 70% of funds to private nonprofit organizations, and assurances that shelter locations will not be .de public and that no income eligibility standard will be imposed on those seeking services. All grantees must match their Federal funds with local funds. While the major focus of this bill is spouse abuse, "domestic violence" is defined to include elder abuse as well. The bill also includes a separate title directing the Secretary of DHHS to conduct a study of the nature and incidence of elder abuse and to report the findings to Congress, along withgreconmendations for legislation to address the problem. H.R. 2977 introduced Mar. 1a, 1979; referred to Committee on Education hand Labor. Reported, amended, Nov. 13, 1979 (H.Rept. 96-613). Passed House, amended, Dec. 12, 1979. Referred in Senate to Committee on Labor and Human Resources. Reported may 9, 1980 “without recommendation." S. 1803 introduced Sept. 28, 1979; referred to Committee on Labor and Human Resources. Reported favorably, amended, May 7, 1980 (S.Rept. 96-685). Debated and amended on Senate floor, Aug. 25 and 26, 1980. Text of S. 1803, as amended, substituted for House—passed version of H.R. 2977. Passed Senate, amended, Sept. 0, 1980. Conferees completed action, Sept. 23, 1980. H.R. 7551 (Dakar et al.) Prevention, Identification, and Treatment of Adult Abuse Act of 1980. Establishes a National Center on Adult Abuse in DHHS, to develop and disseminate information and materials, conduct research, and provide technical assistance for the prevention and treatment of adult abuse. Also authorizes: (1) direct grants to public of adult abuse. Also authorizes: ’ ‘ direct grants to public agencies and private nonprofit organizations, and g.) State grants to qualifying States, for projects related to preventing, identifying, and treating adult abuse. Provides that, in order for States to qualify for Federal funds, they must fulfill certain requirements, including provisions for mandatory reporting of adult.abuse, prompt investigation of such reports, and immunity from prosecution for those who report suspected cns- 3 nB80223 UPDATE-09/25/80 abuse; assurances of cooperation between State agencies, lawvwenforcement officials, and the cofirts with respect to abuse cases: ands assflmnnces that the abused adult hill participate in decisions regarding her or his welfare Introduced June 11, 1980; referred to Committee on Interstate «afidw Forei Commerce, and Committee on Education and Labor. as Wessuaiwaar-gm UNlV'E!$23i‘TF»r" ‘“ . :L&%Egfim1 ; 1