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Categories, Signs and Symptoms of Adult Abuse

AMENDMENT

In May 2018, information was added with regards to self neglect and restraint as defined under the Mental Capacity Act.


  • Discriminatory abuse - links into all other forms of abuse. It exists when values, beliefs or culture result in a misuse of power that denies mainstream opportunities to some groups or individuals. It includes discrimination on the basis of race, gender, age, sexuality, disability, culture or religion:
    • Examples of behaviour: unequal treatment, verbal abuse, inappropriate use of language, slurs, harassment, deliberate exclusion;
    • Signs and Symptoms: lack of respect shown to an individual; signs of a sub-standard service offered to an individual; repeated exclusion from rights afforded to citizens such as health, education, employment, criminal justice and civic status.
  • Physical Abuse - The non-accidental infliction of physical force that results in bodily injury, pain or impairment:
    • Examples of behaviour: hitting, slapping, pushing, kicking, misuse of medication, restraint or inappropriate sanctions. N.B. Inadvertent physical abuse may also arise from poor practice e.g. poor manual handling techniques;
    • Signs and Symptoms: the signs are often evident but can also be hidden by the abuser or the victim. Any unexplained injuries should always be fully investigated;
    • Evidence to look out for includes: any injury not fully explained by the history given; injuries inconsistent with the lifestyle of the Adult at Risk; bruises and/or weals on face, lips, mouth, torso, arms, back, buttocks, thighs; clusters of injuries forming regular patterns or reflecting the shape of an article; burns, especially on soles, palms or back; from immersion in hot water, friction burns, rope or electric appliance burns; multiple fractures; lacerations or abrasions to mouth, lips, gums, eyes, external genitalia; marks on body, including slap marks, finger marks; injuries at different stages of healing; medication misuse.
  • Sexual Abuse - including rape and sexual assault or sexual acts to which the Adult at Risk has not consented, or is incapable of giving informed consent or was pressurised into giving consent:
    • Examples of behaviour: Non-contact: inappropriate looking, photography, indecent exposure, harassment, serious teasing or innuendo, pornography. Contact: touch e.g. of breast, genitals, anus, mouth, masturbation of either or both persons, penetration or attempted penetration of the vagina, anus, mouth, with or by penis, fingers, other objects;
    • Signs and Symptoms: significant change in sexual behaviour or attitude; pregnancy in a woman who is unable to consent to sexual intercourse; wetting or soiling; poor concentration; Adult at Risk appears withdrawn, depressed, stressed; unusual difficulty or sensitivity in walking or sitting; torn, stained or bloody underclothing; bruises, bleeding, pain or itching in genital area; sexually transmitted diseases, urinary tract or vaginal infection, love bites; bruising to thighs or upper arms; self-harming behaviour.
  • Psychological Abuse - Emotional abuse; threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or support networks. It includes the denial of basic human and civil rights, such as choice, self-expression, privacy and dignity:
    • Examples of behaviour: treating a person in a way which is inappropriate to their age and/or cultural background, blaming, swearing, intimidation, insulting, harassing, ‘cold-shouldering’, deprivation of contact;
    • Signs and Symptoms: change in appetite; low self esteem, deference, passivity, and resignation; unexplained fear, defensiveness, ambivalence; emotional withdrawal; sleep disturbance; self harming behaviour.
  • Financial or Material Abuse - The unauthorised and improper use of funds, property or any resources belonging to an individual. Those who financially abuse may be people who hold a position of trust, power, authority or has the confidence of the Adult at Risk:
    • Examples of behaviour: misappropriating money, valuables or property, forcing changes to a will and testament, preventing access to money, property, possessions or inheritance, stealing;
    • Signs and Symptoms: unexplained sudden inability to pay bills or maintain lifestyle; unusual or inappropriate bank account activity; Lasting Power of Attorney or Enduring Power of Attorney obtained when Adult at Risk is unable to comprehend and give consent; withholding money; recent change of deeds or title of property; unusual interest shown by family or others in the Adult at Risk assets; person managing financial affairs is evasive or not co-operative.
  • Neglect and Acts of Omission - The repeated deprivation of assistance that the Adult at Risk needs for important activities of daily living, including a failure to intervene in behaviour which is dangerous to the Adult at Risk or to others, poor manual handling techniques. Self-neglect on the part of an Adult at Risk will not usually lead to the initiation of adult protection procedures unless the situation involves a significant act of commission or omission by someone else with established responsibility for an adult’s care. Other assessment and review procedures, including risk assessment procedures, may prove a more appropriate intervention in situations of self-neglect:
    • Examples of behaviour: failure to provide food, shelter, clothing, heating, medical care, hygiene, personal care, inappropriate use of medication or over-medication;
    • Signs and Symptoms: physical condition of the Adult at Risk is poor, e.g. bed sores, unwashed, ulcers; clothing in poor condition; e.g. unclean, wet, ragged; inadequate physical environment; inadequate diet; untreated injuries or medical problems; inconsistent or reluctant contact with health or social care agencies; failure to engage in social interaction; malnutrition when not living alone; inadequate heating; failure to give prescribed medication; poor personal hygiene.

Self-neglect

This covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support.

Incidents of abuse may be one-off or multiple, and affect one person or more. Professionals and others should look beyond single incidents or individuals to identify patterns of harm. Repeated instances of poor care may be an indication of more serious problems and of what is described as organisational abuse. In order to see these patterns it is important that information is recorded and appropriately shared.

Patterns of abuse vary and include:

  • Serial abuse, in which the perpetrator seeks out and ‘grooms’ individuals. Sexual abuse sometimes falls into this pattern as do some forms of financial abuse;
  • Long-term abuse, in the context of an ongoing family relationship such as domestic violence between spouses or generations or persistent psychological abuse;
  • Opportunistic abuse, such as theft occurring because money or jewellery has been left lying around.

  • Institutional Abuse - arises from an unsatisfactory regime. It occurs when the routines, systems and norms of an institution override the needs of those it is there to support. It may take the form of isolated incidents of poor practice at one end of the spectrum, through to pervasive ill treatment or gross misconduct at the other. It can occur when the routines, systems, communications and norms of an institution compel individuals to sacrifice their preferred lifestyle and cultural diversity to the needs of that institution. Repeated instances of poor care may be an indication of more serious problems:
    • Examples of behaviour: Inflexible routines set around the needs of staff rather than individual service users, e.g. requiring everyone to eat together at specified times, bathing limited to times to suit staff, no doors on toilets. These can arise through lax, uninformed or punitive management regimes;
    • Signs and Symptoms: inappropriate or poor care; misuse of medication; restraint methods; sensory deprivation, e.g. denial of use of spectacles or hearing aid; lack of respect shown to the Adult at Risk; denial of visitors or phone calls; restricted access to toilet or bathing facilities; restricted access to appropriate medical or social care; failure to ensure appropriate privacy or personal dignity; lack of flexibility and choice, e.g. mealtimes and bedtimes, choice of food; lack of personal clothing or possessions; lack of privacy; lack of adequate procedures, e.g. for medication, financial management; controlling relationships between staff and service users; poor professional practice.
  • The Use of Restrictive Physical Interventions: Restrictive physical interventions are only justified when they are used in the best interests of the service user him or herself or to protect the safety of others. Intrusive forms of physical interventions, which are often used as a response to violence, are potentially harmful:
    • A care service will always have a policy statement which makes explicit the safeguards which must be in place before physical intervention is used. This affords protection to a service user, to staff and to the organisation;
    • Physical interventions which are used routinely and which are not the subject of consultation (i.e. with the person him or herself or with relatives, professionals and others with a legitimate interest), recording and review will normally be considered abusive.

Restraint is defined under the Mental Capacity Act as;

  1. Any act that uses, or threatens to use, force to carry out another function to which the person resists; or
  2. Any act that restricts the person’s freedom of movement, whether or not they resist.

If the adult has capacity then no form of restraint can be used against them without their consent. This is abuse.

If the adult lacks capacity the decision to use restraint must be made in their Best Interests, and only when;

  1. The Decision Maker believes that it is necessary to restrain the adult in order to prevent them from being harmed; and
  2. There is evidence that restraint is a proportionate response to the likelihood and seriousness of harm.

The use of restraint outside of these circumstances is likely to be either;

  1. Abuse; or
  2. A Deprivation of Liberty (which requires appropriate authorisation).

Indicators that the restraint may require authorisation under the relevant Deprivation of Liberty framework include;

  1. Frequent use of restraint;
  2. Cumulative use of restraint;
  3. Ongoing use of restraint.

Domestic Violence

The cross-government definition of domestic violence and abuse is: any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to:

  • Psychological;
  • Sexual;
  • Financial;
  • Emotional.

An offence of coercive and controlling behaviour in intimate and familial relationships was introduced into the Serious Crime Act 2015. The offence imposes a maximum 5 years imprisonment, a fine or both.

See: Statutory guidance framework: controlling or coercive behaviour in an intimate or family relationship for further information.

Modern slavery is also included as a category of abuse and neglect and encompasses:

  • Slavery;
  • Human trafficking;
  • Forced labour and domestic servitude;
  • Traffickers and slave masters using whatever means they have at their disposal to coerce, deceive and force individuals into a life of abuse, servitude and inhumane treatment.

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