Signs and Indicators of Adult Abuse

Indicators are the main signs and symptoms, which suggest that some form of abuse may have occurred, but caution is suggested against establishing adult abuse merely due to the presence of one or more of these indicators without further detailed assessment/investigation. Typically an abusive situation will involve indicators from a number of groups in combination.

Physical AbusePhysical injuries which have no satisfactory explanation or where there is a definite knowledge, or a reasonable suspicion that the injury was inflicted with intent, or through lack of care, by the person having custody, charge or care of that person, including hitting, slapping, pushing, misuse of or lack of medication, restraint, or inappropriate sanctions.

Possible Indicators of physical abuse

  • History of unexplained falls or minor injuries especially at different stages of healing
  • Unexplained bruising – in well protected areas, on the soft parts of the body or clustered as from repeated striking
  •  Unexplained burns in unusual location or of an unusual type e.g. burns caused by cigarettes and rope burns etc
  • Unexplained fractures to any part of the body that may be at various stages in the healing process
  • Unexplained lacerations or abrasions
  • Slap, kick, pinch or finger marks
  • Injuries/bruises found at different stages of healing or such that it is difficult to suggest an accidental cause
  • Injury shape similar to an object
  • Untreated medical problems
  • History of frequent changing of General Practitioners or reluctance against General Practitioner consultation or visit
  • Weight loss – due to malnutrition or dehydration; complaints of hunger
  • Appearing to be over medicated
  • Accumulation of medicine which has been prescribed for the client but not administered
  •  ulcers, bed sores and being left in wet clothing.

Psychological Abuse - Psychological, or emotional abuse, includes the use of threats, fears or bribes to negate a vulnerable adult’s choices, independent wishes and self esteem; Cause isolation or over-dependence (as might be signalled by impairment of development or performance) or prevent a vulnerable adult from using services, which would provide help.

Possible Indicators of psychological abuse

  • Ambivalence about carer
  • Fearfulness expressed in the eyes; avoids looking at the carer, flinching on approach
  • Deference
  • Overtly affectionate behaviour to alleged perpetrator
  • Inability to sleep or tendency to spend long periods in bed
  • Change in appetite -  Loss of appetite or overeating at inappropriate times
  • Unusual weight gain/loss
  • Tearfulness
  • Unexplained paranoia
  • Low self-esteem
  • Excessive fears
  • Anxiety, confusion or general resignation
  • Agitation
  • Sexual Abuse
  • Sexual acts which might be abusive include non-contact abuse such as looking, pornographic photography, indecent exposure, harassment, unwanted teasing or innuendo, or contact such as touching or penetration.

Possible Indicators of sexual abuse

  • A change in usual behaviour for no apparent or obvious reason
  • Sudden onset of confusion, wetting or soiling
  • Withdrawal, choosing to spend the majority of time alone
  • Overt sexual behaviour/language by the vulnerable person which is out of character
  • Self-inflicted injury
  • Irregular and Disturbed sleep pattern and poor concentration
  • Difficulty in walking or sitting
  • Torn, stained, bloody underclothes
  • Love bites
  • Pain or itching, bruising or bleeding in the rectal or genital area
  • Sexually transmitted urinary tract/vaginal infections
  • Bruising to the thighs and upper arms
  • Frequent infections
  • Severe upset or agitation when being bathed/dressed/undressed/medically examined
  • Pregnancy in a person not able to consent

Domestic Violence and Abuse
As well as physical violence, examples of domestic abuse can involve: undermining an individual’s self-confidence; threats to others including children; controlling behaviour such as isolation from friends and family; restricting access to money, personal items, food, telephone etc; and stalking.

Possible Indicators of Domestic Violence and abuse

  • Destructive criticism and verbal abuse: shouting/mocking/accusing/name calling/verbally threatening
    Pressure tactics: sulking, threatening to withhold money, disconnect the telephone, commit suicide, take the children away, report you to welfare agencies, lying to your friends and family about you, telling you that you have no choice in any decisions
  • Disrespect: persistently putting you down in front of other people, not listening or responding when you talk, refusing to help with childcare or housework
  • Breaking trust: lying to you, withholding information from you, being jealous, having other relationships
  • Isolation: monitoring or blocking your telephone calls, telling you where you can and cannot go, preventing you from seeing friends and relatives
  • Harassment: following you, checking up on you, opening your mail, repeatedly checking to see who has telephoned you
  • Threats: making angry gestures, using physical size to intimidate, shouting you down, destroying your possessions, breaking things, punching walls, wielding a knife or a gun, threatening to kill or harm you and the children
  • Sexual violence: using force, threats or intimidation to make you perform sexual acts, having sex with you when you don't want to have sex
  • Physical violence: punching, slapping, hitting, biting, pinching, kicking, pulling hair out, pushing, shoving, burning, strangling
  • Denial: saying the abuse doesn't happen, saying you caused the abusive behaviour, being publicly gentle and patient, crying and begging for forgiveness, saying it will never happen again.

Financial Abuse
Usually involves an individual’s funds or resources being inappropriately used by a third person. It includes the withholding of money or the inappropriate or unsanctioned use of a person’s money or property or the entry of the vulnerable adult into financial contracts or transactions that they do not understand, to their disadvantage.

Possible Indicators of financial abuse

  • Unexplained or sudden inability to pay household shopping or bills etc
  • Unexplained or sudden withdrawal of money from accounts
  • Person lacks belongings or services or Living conditions are substandard and unsatisfactory in contrast to adult's apparent financial position
  • Lack of receptiveness to any necessary assistance requiring expenditure, when finances are not a problem – although the natural thriftiness of some people should be borne in mind
  • Unusual and extraordinary interest and involvement by the family, carer, friend, stranger or door to door salesperson in vulnerable adult's assets
  • Power of Attorney obtained when the vulnerable adults is not able to understand the purpose of the document they are signing
  • Recent change of deeds or title of property
  • Carer only asks questions of the worker about the user’s financial affairs and does not appear to be concerned about the physical or emotional care of the person
  • The person who manages the financial affairs is evasive or uncooperative
  • A reluctance or refusal to take up care assessed as being needed
  • A high level of expenditure without evidence of the person benefiting
  • The purchase of items which the person does not require or use
  • Personal items going missing from the home Unreasonable and /or inappropriate gifts

Neglect / Acts of Omission
Neglect can be both physical and emotional it is about the failure to keep a vulnerable adult clean, warm and promote optimum health, or to provide adequate nutrition, medication, being prevented from making choices
Neglect of a duty of care or the breakdown of a care package may also give rise to safeguarding issues i.e. where a carer refuses access or if a care provider is unable, unwilling or neglects to meet assessed needs. If the circumstances mean that the vulnerable adult is at risk of significant harm then Safeguarding Adults procedures should be invoked.

Possible Indicators of neglect

  • Poor condition of accommodation
  • Inadequate heating and/or lighting
  • Physical condition of person poor, e.g. ulcers, pressure sores etc
  •  Person’s clothing in poor condition, e.g. unclean, wet, etc.  Clothing may be inappropriate or inadequate, or the person may be kept in night clothes during the day
  • Sensory deprivation, not allowed to have access to glasses, hearing aids etc
  • Vulnerable adult has no method of calling for assistance
  • Apparently unexplained weight loss. Malnutrition – inadequate food or fluids
  • Failure to give prescribed medication or obtain appropriate medical care
  • Failure to ensure appropriate privacy and dignity
  • Carers inconsistent or reluctant to accept contact from health or social care professionals
  • Refusal of access to callers/visitors
  • A person with capacity may choose to self-neglect, and whilst it may be a symptom of a form of abuse it is not abuse in itself within the definition of these procedures.

Discriminatory Abuse
Is abuse targeted at a perceived vulnerability or on the basis of prejudice including racism or sexism, or based on a person's disability. It can take any of the other forms of abuse, harassment, slurs or similar treatment.
Discriminatory abuse may be used to describe serious, repeated or pervasive discrimination, which leads to significant harm or exclusion from mainstream opportunities, provision of poor standards of health care, and/or which represents a failure to protect or provide redress through the criminal or civil justice system.

Possible Indicators of discriminatory abuse

  • hate mail
  • verbal or physical abuse in public places or residential settings
  • criminal damage to property
  • target of distraction burglary, bogus officials or unrequested building/household services
  • Tendency to withdrawal and isolation
  • Fearfulness and anxietyBeing refused access to services or being excluded inappropriately
  • Loss of self esteem
  • Resistance or refusal to access services that are required to meet need
  • Expressions of anger and frustration

Institutional Abuse
Institutional abuse happens when the rituals and routines in use, force residents or service users to sacrifice their own needs, wishes or preferred lifestyle to the needs of the institution or service provider. Abuse may be perpetrated by an individual or by a group of staff embroiled in the accepted custom, subculture and practice of the institution or service.

Possible indicators of institutional abuse

  • may be reflected in an enforced schedule of activities, the limiting of personal freedom, the control of personal finances, a lack of adequate clothing, poor personal hygiene, a lack of stimulating activities or a low quality diet – in fact, anything which treats service users as not being entitled to a “normal” life

Institutions may include residential and nursing homes, hospitals, day centres sheltered housing schemes, group or supported housing projects. It should be noted that all organisations and services, whatever their setting, can have institutional practices which can cause harm to vulnerable adults.

The distinction between abuse in institutions that results from poor standards of care, lack of knowledge, understanding and training and specific allegations of abuse of one or more named service users by the service or by staff within a service requires careful consideration. Depending upon the allegation and nature of the abuse, different interventions and action will be necessary by one or more agencies such as Joint Protocol investigations, care management, regulatory authorities (RQIA), contract departments etc.