1. Michael Hansen, Director
The Silent Epidemic: Abuse, Neglect, and Exploitation of Individuals with Developmental Disabilities Family Café Presentation June 2012
Rick Scott, Governor
Michael Hansen, Director

2. A Day in the Life…

3. Objectives Understand nature and prevalence of the problem
Learn to recognize common signs and symptoms of abuse, neglect, and exploitation and what actions to take
Know the best ways to prevent such crimes before they occur

4. Statutory Definitions
There are a number of laws in Florida which define and describe abuse, neglect and exploitation committed against children and adults with developmental disabilities by their caregivers (either paid or unpaid).

5. Child Abuse
"Abuse" means any willful act or threatened act that results in any physical, mental, or sexual injury or harm that causes or is likely to cause the child's physical, mental, or emotional health to be significantly impaired. Abuse of a child includes acts or omissions. Corporal discipline of a child by a parent or legal custodian for disciplinary purposes does not in itself constitute abuse when it does not result in harm to the child From Section 39.01(2), Florida Statutes

6. Adult Abuse
"Abuse" means any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult's physical, mental, or emotional health. Abuse includes acts and omissions.
From Section (1), Florida Statutes

7. Examples of Abuse
Hitting, pushing, hair pulling, choking, kicking, biting, assault, or rough/inappropriate handling.
Inappropriate/overuse of restraints
Over-medicating or inappropriate behavioral interventions (including bizarre punishments)
Verbal harassment and threats
Unwanted sexual touching of private body parts
Unwanted display of sexual parts (pornography, exhibitionism)
Tricking or manipulating someone into sexual activity, sexual assault, or rape.

8. Examples of Physical Abuse in Caregiving
Rough physical handling
Sudden movements of bedding
Pushing and pulling
Over-medication
Unnecessary or excessive use of restraints
Bathing in water that is too hot or too cold

9. Examples of Emotional Abuse
Exposure to domestic violence
Insults and harassment
Denial of conditions necessary for physical and emotional well-being
Denial of communication
Denial of right to family life
Denial of social interaction and inclusion
Denial of economic stability
Denial of rights, needs, privileges, and opportunities
Denial of ordinary freedoms

10. Frightening Physical Actions
Grabbing persons with visual impairments from behind
Jumping in front of persons with visual impairments, or trying to trip them
Abruptly moving persons with mobility impairments
Forcing persons with physical disabilities to move from one position to another when they are exhausted or in pain

11. From Section 39.01(45), Florida Statutes
Child Neglect
“Neglect" occurs when a child is deprived of, or is allowed to be deprived of, necessary food, clothing, shelter, or medical treatment or a child is permitted to live in an environment when such deprivation or environment causes the child's physical, mental, or emotional health to be significantly impaired or to be in danger of being significantly impaired….Neglect of a child includes acts or omissions.
From Section 39.01(45), Florida Statutes

12. Neglect of an Adult
"Neglect" means the failure or omission on the part of the caregiver or vulnerable adult to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult, including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, which a prudent person would consider essential for the well-being of a vulnerable adult. The term "neglect" also means the failure of a caregiver or vulnerable adult to make a reasonable effort to protect a vulnerable adult from abuse, neglect, or exploitation by others. "Neglect" is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death From Section (15), Florida Statutes

13. Self-Neglect
Florida law was recently changed to include a category under neglect of an adult called "self-neglect."
Besides possibly being neglected by a caregiver, the potential exists for people to neglect themselves because of either their age or disability.
Anyone who knows or suspects that an adult with a developmental disability is the victim of self-neglect must report such information.

14. Examples of Neglect
Not working assigned hours or not performing duties
Mistreating service animals
Withholding medications, food, medically necessary treatment, or assistive equipment
Withholding necessary personal/medical care (such as re-positioning individuals with mobility impairments)
Ignoring dietary restrictions
Leaving individuals alone without a way to call for help
Not providing appropriate levels of supervision which result in harm to person.
Leaving individuals in bed all day or not getting them dressed
Leaving individuals on the toilet or in soiled undergarments for long periods of time

15. Examples of Environmental Neglect
Injury caused by leaving a loaded gun or other weapon accessible to the person
Unsanitary/unsafe living conditions
Inadequate clothing (especially for the prevailing weather conditions)
Inadequate food

16. Exploitation “Exploitation" means a person who:
1.  Stands in a position of trust and confidence with a vulnerable adult and knowingly, by deception or intimidation, obtains or uses, or endeavors to obtain or use, a vulnerable adult's funds, assets, or property with the intent to temporarily or permanently deprive a vulnerable adult of the use, benefit, or possession of the funds, assets, or property for the benefit of someone other than the vulnerable adult; or
2.  Knows or should know that the vulnerable adult lacks the capacity to consent, and obtains or uses, or endeavors to obtain or use, the vulnerable adult's funds, assets, or property with the intent to temporarily or permanently deprive the vulnerable adult of the use, benefit, or possession of the funds, assets, or property for the benefit of someone other than the vulnerable adult.
From Section (7), Florida Statutes

17. Examples of Exploitation
Using the car, money or other possessions of someone with a disability without their consent.
Tricking or threatening the person to purchase an item or service that they do not want or that will not be used for their benefit.

18. The Sexual Misconduct Law
Florida Statutes now include a new crime called “sexual misconduct” which is defined as any sexual activity between a service provider and certain individuals with developmental disabilities
Makes the crime punishable as a second degree felony
Makes failure to report known or suspected cases of sexual misconduct a first degree misdemeanor
Eliminates consent by the consumer as a valid defense against prosecution for this crime
Expands Level 1 and 2 background screening requirements to include the newly-created crime of sexual misconduct as a disqualifying offense for employment
(From , Florida Statutes)

19. Aggravated Abuse of an Elderly Person or Disabled Adult
"Aggravated abuse of an elderly person or disabled adult" occurs when a person:
(a) Commits aggravated battery on an elderly person or disabled adult
(b) Willfully tortures, maliciously punishes, or willfully and unlawfully cages, an elderly person or disabled adult; or
(c) Knowingly or willfully abuses an elderly person or disabled adult and in so doing causes great bodily harm, permanent disability, or permanent disfigurement to the elderly person or disabled adult.
A person who commits aggravated abuse of an elderly person or disabled adult commits a felony of the first degree, punishable as provided in s , s , or s
From Section (2), Florida Statutes

20. Incidence Studies
Much research has been done which shows the high rate of abuse, neglect, and exploitation committed against people with disabilities.

21. What does the data say?
An estimated 90% of people with mental retardation will experience sexual violence at least once during their lives.
Another study showed that, among children with disabilities, 61% of girls and 25% of boys had been sexually abused before the age of 18.
Compared to children without disabilities, children with mental retardation were:
3.7 times as likely to have been neglected
3.8 times as likely to be physically abused
4.0 times as likely to be sexually abused
3.8 times as likely to be emotionally abused

22. Additional research…
A 2006 study involving over 7,000 women with and without disabilities revealed that the women with disabilities were 40% more likely than their disabled peers to have been the victims of domestic violence.
Of 177 women with physical disabilities, 56% reported having been abused during their lifetime.
A survey of 342 men with disabilities who used personal care assistance services found that 55% had experienced physical abuse while 25% had been sexually abused.
Only 3% of sexual abuse cases (involving people with developmental disabilities) are ever reported.

23. Frequency of Sexual Abuse
(1 time)
( times)
(10 + times)
Source: “The sexual abuse of young people with disabilities: Treatment considerations”, Mansell, Sobsey and Calder, 1992

24. Frequency of Exploitation
A 2001 study conducted by the National Association of Adult Protective Service Administrators (NAAPSA) reported 38,015 documented reports of financial exploitation committed against elderly and vulnerable adults.
It is believed that only 1 in 14 cases get reported, meaning that the number of yearly cases of financial exploitation could be as high as 850,000.

25. Why are people with developmental disabilities more likely to be victimized?
may be physically unable to defend themselves
may require assistance with the most personal and intimate activities of daily living
may be unable to report the crime
may not be considered credible reporters
may be unable to differentiate between appropriate and inappropriate touching
are often taught to be passive and compliant
may be coerced or threatened with the withholding of needed care or equipment
may be socially isolated

26. Risk Factors Dependence on others for long-term care
Lack of economic independence
Receives services in segregated settings
Lack of participation in abuse awareness and personal safety programs
Less education about sexuality and healthy intimate relationships
Social isolation
Overprotection
Communication challenges
Physical barriers to accessing supports and services (such as lack of transportation or inaccessible domestic violence/sexual assault shelters)*
*Source: “Combating Violence & Abuse of People with Disabilities: A Call to Action.” By Nancy Fitzsimmons. Baltimore, Maryland: Paul H. Brookes Publishing Company, 2009.

27. Common Case Characteristics
People with developmental disabilities are more likely to experience:
Different types of abuse, neglect, and exploitation
Multiple perpetrators
Abuse, neglect, and exploitation which is more severe and lasts for longer periods of time than people without disabilities
Abused more frequently than others
Less able to escape the abuse, find justice or services
More likely to remain in situations that increase their vulnerability and risk of repeated abuse

28. Where does abuse, neglect, and exploitation most often occur?
Family Home
Assisted Living
Facility
Apartment
Foster Home
Intermediate
Care Facility
Group Home

29. Who are the Abusers? WHO IS A TYPICAL ABUSER? HOW OLD ? WHAT RACE?
WHAT GENDER?

30. CHARACTERISTICS OF AN ABUSER
can represent any racial, religious, or socioeconomic group
are most frequently male (for sexual abuse)
are usually known to the victim
can be of any age
ANYONE WITH A HISTORY OF BEING A ABUSER IS AT HIGH RISK OF DOING SO AGAIN!!!

31. Profiles of Abusive Caregivers
Caregivers with limited capacity
Stressed caregivers
Batterers (intentional abusers)
Caregivers with Munchausen Syndrome by Proxy (MSBP) or other Factitious Disorders

32. Behaviors of Caregivers who may be Abusers
Refusal to follow directions or complete necessary personal tasks
Displaying controlling attitudes and behaviors
Showing up late or not at all
Working under the influence of alcohol or illegal drugs
Abusing or harming pets or service animals
Using threats or menacing looks/body language as a form of intimidation
Impulsive

33. More abusive caregiver behaviors...
Using vehicle, money or other resources without consent
Socially isolating person with a disability (including limiting educational and/or employment opportunities)
Devalues the person with developmental disabilities
Frequently switches healthcare providers
Speaks for the person with developmental disabilities
Competes with the person with developmental disabilities for attention
Displays unwelcoming or uncooperative attitude during home visits
Frequently makes attempts to be alone with a particular individual for no apparent legitimate purpose

34. Abusive caregivers may also have…
Low self-esteem
A mental illness, diminished intelligence, or impaired functioning
A need to control others
Frustration with authority, which can lead to displaced aggression toward weaker persons
A history of being abused or neglected as a child
A lack of attachment to the dependent person, (which can lead to thoughts by the abuser that the victim doesn’t feel or hurt in response to their abusive actions).

35. WHAT ARE SOME SIGNS AND SYMPTOMS OF ABUSE, NEGLECT AND EXPLOITATION
WHAT ARE SOME SIGNS AND SYMPTOMS OF ABUSE, NEGLECT AND EXPLOITATION? IF YOU HAD TO CHOOSE ONE THING THAT WOULD BE THE MOST IMPORTANT INDICATOR, WHAT WOULD IT BE?

36. The single most important thing to look for in a person with a developmental disability to indicate the possibility of abuse, neglect, or exploitation is change. A sudden or gradual change in appearance or behavior should always be noted and monitored.

37. Physical Signs of Abuse
Bruises
Burns
Cuts
Broken bones
Sprains
Scrapes or Abrasions
Bleeding from the ears, nose or mouth

38. Questionable Bruises Facial
Frequent, unexplained, or inadequately explained
In unlikely places
In various stages of healing
On several different surface areas
Patterned, reflecting shapes
Bilateral: means bruises on same places on both sides of the body. Bruises appearing on both upper arms, for example, may indicate where the abuser applied pressure while forcefully shaking the person. Bruises on both sides of the body rarely result from accidental causes.
Regularly evident after an absence, home visit, or vacation

39. Questionable Cuts and Scrapes
Frequent, repeated, unexplained, or inadequately explained scrapes
Unusual locations such as mouth, lips, gums, eyes, external genitalia (e.g., places other than palms, knees, or other areas usually covered by clothing)
Patterned scarring that may be caused by inflicted injuries such as whipping

40. Burns or Scalds
Patterned burns (shaped like a cigarette butt or electrical appliance for example)
Burns in specific locations such as several burns on different parts of the body or on particularly sensitive locations, such as soles, palms, back, or buttocks
Immersion burns, which appear sock-like, glove-like, or doughnut-shaped on buttocks, genitalia, or limbs

41. Bites
Human bite marks are easily distinguished from those of animals by their size and shape (human bite marks are arch-shaped while dog bites are typically in a shape of points) and whether flesh is torn (human bites typically don’t result in the tearing of flesh).
If bites are explained as self-inflicted, the location and position of the bite must be consistent with the person’s functional abilities.

42. Ligature Marks and Welts
Could be the result of a whipping, being tied up, or gagged
Welts often follow clearly defined stroke patterns, especially if the person was immobile during the whipping
Chafing and bruising, sometimes accompanied by swelling, on the wrists, ankles, throat, or penis can be the result of being tied up or choked
Even when choking is severe or fatal, bruising may be faint or entirely absent

43. Eye and Ear Injuries Sudden or unexplained hearing loss
Cauliflower ears (i.e., thickened external ear structures)
Bruising to the outer ears
Blood behind the eardrum
Retina hemorrhage or other intraocular bleeding

44. Dental and Mouth Injuries
Lost or broken teeth, particularly if unrelated to dental disease, normal loss of children’s teeth, or accidental causes
Repeated, unexplained, or inadequately explained dental injuries
Facial bone or jaw fractures
Bruising of cheeks and gums at corners of mouth (from gags)
Cuts or bruises on the tongue
Discoloration of the teeth as a result of previous abuse

45. Dislocations of Joints
Repeated dislocations of joints in the absence of a known disease process may indicate shaking, twisting, or pulling
Frequent or multiple dislocations in the absence of a clear explanation may indicate physical abuse

46. Fractures
Repeated or multiple fractures in the absence of a known disease process or clear explanation may indicate abuse
Old, untreated fractures can indicate chronic abuse
Spiral fractures that result from twisting limbs may be related to abuse in non-ambulatory children and adults with developmental disabilities

47. Coma
Shaking and other forms of abuse can result in coma of undetermined origin without external injuries. Comas not associated with known accidental causes or clearly identified disease processes should also be suspected.

48. Things to consider in distinguishing abuse from accidental injuries...
Location of the injury
Number and frequency of injuries
Size and shape of injury
Description of how the injury occurred
Consistency of the injury with the person’s developmental capability

49. Physical Signs of Sexual Abuse
Frequent urinary tract infections or yeast infections
Painful urination
Abrasions, bleeding, or bruising in the genital area
Incontinence in someone who was previously toilet-trained
Frequent sore throats
Sudden onset of psychosomatic complaints (males most frequently complain of stomach aches while females most frequently report headaches)
Sudden difficulty walking or sitting
Vaginal or rectal pain

50. Physical Signs of Neglect
Bedsores
Dehydration
Poor or improper hygiene
Malnourishment/weight loss
Lack of necessary adaptive aids (such as hearing aids, eyeglasses, walkers, etc.)
Improper medication management

51. Behavioral Signs
CHANGES in the way affection is shown, especially if unusual or inappropriate
Suddenly fears being touched
Sudden onset of nightmares
CHANGES in sleep patterns; difficulty sleeping
Sudden regression to childlike behaviors (i.e., bed-wetting, thumb-sucking)
Sudden unusual interest in or knowledge of sexual matters (including excessive masturbation)
Cruelty to animals
Sudden fear of bathing or toileting
Sudden fear of a person or place
Depression, withdrawal, or mood swings
ANY UNEXPLAINED CHANGE IN BEHAVIOR

52. Signs and Symptoms of Exploitation
Sudden decrease in bank account balances
Sudden change in banking practices (such as making several large withdrawals from a bank account or ATM over a period of several days instead of one small withdrawal each week)
Sudden problems paying bills or buying food or other necessities
Sudden changes in wills or other financial documents

53. More signs of exploitation...
The person begins to act very secretively. (Telephone con artists often try to isolate their victims to avoid detection by telling the victim not to let anyone know about their calls.)
Unexplained disappearance of money or valuable possessions
Substandard care being provided or bills which are late or unpaid despite the availability of adequate financial resources
Concerns expressed by a person with a developmental disability that he or she is being exploited

54. Factors That Make it Hard to Recognize Abuse, Neglect and Exploitation
Victim does not recognize abuse, neglect, or exploitation
Communication challenges (which prevent both disclosure of the event and resulting problems)
Self-abusive behaviors
Some symptoms may be interpreted as behavioral problems or traits of their disability
There is no universal response to abuse, neglect or exploitation. Every individual responds differently, and in some cases there may be no outward signs at all.

55. Conditions that can Sometimes Look Like Abuse or Neglect
Injuries due to falls
Sensory impairments
Skin breakdown from appliances or orthopedic equipment
Self-injurious behavior (SIB)
Poor growth and failure to thrive
Fractures
Sensory integration problems
Mongolian spots

56. Mandatory Reporting Requirements
Failure to report known or suspected cases of abuse, neglect, or exploitation is a crime.
Keep in mind that service providers can also lose their jobs and/or face legal action for failing to report.
When in doubt, report; it is always better to make a mistake on the side of caution to keep people safe from harm.
Reports should be made even if the incident happened a long time ago or in a school.

57. A word about “Mandatory” Reporters…
Abuse/neglect reporting laws were changed a few years ago so that any person who has knowledge or suspicion that a child or a vulnerable adult is being abused, neglected, or exploited is now required by law to report such information.
Certain professions (identified in statute) are, however, required to provide their name when reporting while all others may submit reports anonymously if they prefer.

58. How to Report Abuse, Neglect, or Exploitation
The Department of Children and Families (DCF) operates the Florida Abuse Hotline and is the state agency responsible for receiving and investigating allegations of abuse, neglect, or exploitation of children and adults with developmental disabilities committed by their caregivers.
If you know or suspect abuse, neglect, or exploitation, call the Abuse Hotline, which is a nationwide, toll-free telephone number, at ABUSE ( ), or send a faxed statement to the Abuse Hotline’s statewide toll-free fax number, 24 hours a day, 7 days a week, at ), or

59. Information That May be Requested by Florida Abuse Hotline Operators
Name, age, sex, physical description, and location of each victim alleged to have been abused, neglected, or exploited
Names, addresses, and telephone numbers of each alleged perpetrator
Name, address, and telephone number of the person reporting the alleged abuse, neglect, or exploitation
Description of the physical or psychological injuries
Actions taken by the reporter, if any, such as notification of the police
It is important that you don’t delay calling the hotline just because you may not have all of the above information!!!

60. What Happens After the Abuse Hotline is Contacted
Within 24 hours of receiving and accepting a report, a DCF protective investigator will make a face-to-face contact with the alleged victim. If access to the alleged victim is denied to the protective investigator, the police will be called to assist.

61. What happens if the hotline does not accept the call?
If you believe that your call should have been accepted and/or that the hotline operator did not handle the call properly, please call the hotline back and ask to speak to a supervisor to explain the situation.
Calls not accepted by the hotline (because the allegation does not involve abuse, neglect, or exploitation of a child or vulnerable adult by a caregiver) will automatically be transferred by hotline staff to the local police.

62. When NOT to call the Hotline first…
If you know about a
situation in which the
life of a person with a
developmental disability
is in immediate danger
due to abuse, neglect,
or exploitation, you
should call 911 before
calling anyone else.

63. Barriers to Reporting
Victims sometimes refuse to acknowledge that there is a problem
Persons with disabilities are often taught to be compliant and passive and are sometimes unable to distinguish between appropriate and inappropriate physical contact
Persons with disabilities may feel their report of abuse would not be believed
Physical/cognitive impairments make it difficult for the victim to seek help

64. More barriers...
Most augmentative communication systems (such as communication boards used by people who cannot speak) are not programmed to report abuse, neglect or exploitation.
Victims do not know where to turn for help, and they are often isolated
Victims may believe they are financially or otherwise dependent on the abuser for their needs;
Victims fear loss of a caregiver, even an abusing caregiver; they are fearful they will be forced to leave their current families or homes. Persons with disabilities may be more easily threatened by the withholding of needed care or equipment.

65. There is a general lack of understanding or awareness of the high rate of these types of crimes.
People often do not recognize abuse and are quick to dismiss the visible signs of abuse by saying it was probably caused by the person’s disability.
Most people assume that no person would be capable of committing certain crimes against persons with disabilities.
Because they haven’t seen actual physical abuse, they may not believe a problem exists.
People fear financial or legal liability and retaliation if they report suspected abuse.
Many people have the mistaken idea that their actions will not make a difference.

66. Your response to a victim should always communicate…
I believe you.
It is not your fault.
You are not alone.
I want to help you.
Source: Reproductive Health Care for Women with Disabilities: An Online Tutorial
( )

67. Navigating the System Education/Training Reporting
Department investigations & law enforcement response (including forensic exams)
Prosecution and Conviction
Victim Services

68. Prevention Methods
Primary
Secondary

69. Primary Prevention Efforts
Research shows that the single most effective way to prevent abuse, neglect, and exploitation is by providing education and self-protection training directly to individuals with disabilities.

70. Training and Education
Self Protection Skills
Assertiveness Training
Appropriate and Inappropriate Behaviors (by both caregivers and the people they serve)
Reporting Problems to Others

71. Additional Tips for Caregivers to Help Prevent Sexual Abuse
Recognize the person’s need to know
Set boundaries
Identify appropriate behavior in public and private
Teach children protective behaviors
Use appropriate names for genitals
Seek help when you need it

72. More primary prevention tips…
Background screening/reference checks/thorough interviews of prospective caregivers
Growing of social circles
Respite for caregivers
Training for caregivers
Education of caregivers on the sexual misconduct law and other laws regarding abuse, neglect, and exploitation.
Becoming familiar with the policies of service providers (including schools) on such issues as restraint, seclusion, and other behavioral interventions

73. Secondary Prevention Efforts
Education of caregivers in recognizing and reporting the signs and symptoms of abuse, neglect, and exploitation.
Unannounced visits at different times of day.
Full cooperation with police and DCF investigators.

74. More secondary prevention tips…
Modification of communication devices so that abuse, neglect, and exploitation can be easily and quickly reported.
Expansion of social circles so that more individuals would be involved in the person’s life and would therefore be able to identify and report suspected cases of abuse, neglect, and exploitation.

75. The Zero Tolerance Initiative
An ongoing effort by the Agency for Persons with Disabilities to address and prevent abuse, neglect, and exploitation committed against Floridians with developmental disabilities

77. Please visit our Zero Tolerance Website at:
For more information...
Please visit our Zero Tolerance Website at:
for the complete and updated Zero Tolerance action plan, news about upcoming activities and events, APD-issued policy statements and additional resources.

78. For additional information or questions concerning the Agency’s Zero Tolerance Initiative, please feel free to contact me at:
or (850)

79. In conclusion...
Thanks!