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Common Signs and Symptoms of Abuse, Neglect, and Exploitation Perhaps the most difficult aspect of recognizing the signs and symptoms of abuse and neglect is that individuals with developmental disabilities may exhibit certain physical and/or behavioral traits due to the nature of their disability. Therefore, it is very important to recognize changes in behavior or health (particularly those not typically associated with the individual's disability) as potential abuse indicators. It is also important to note that there is no universal response to abuse or neglect. Above all else, be mindful that any sudden change in the physical, behavioral, or financial status of someone with a developmental disability may be the result of past or ongoing incidences of abuse, neglect or exploitation.

As you interact with someone with a developmental disability, you should pay close attention to any changes in how that person looks or acts. A sudden or gradual change in appearance or behavior can be an indicator that abuse or neglect has occurred (or may still be happening.)

Physical Signs of Abuse

Bruises (old and new, clustered on one part of body, or on both upper arms)
Burns
Cuts or scars
Marks left by a gag (or some form of restraint)
Imprint injuries (eg., marks shaped like fingers, thumbs, hands, belts or sticks)
Missing teeth
Spotty balding (from pulled hair)
Eye injuries (black eyes or detached retinas)
Broken bones
Sprains
Abrasions or scrapes
Vaginal or rectal pain
Bleeding from the ears, nose or mouth
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 sitting²
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Physical Signs of Neglect (in both the person and their home)

Dehydration
Poor or improper hygiene
Poor grooming (e.g., overgrown fingernails and toenails; uncut, matted, or unclean hair; unshaven facial hair, body crevices caked with dirt)
Malnourishment/weight loss
A smell of urine or feces on the person
Clutter, filth, or bad smell in the home
Improper sleeping, cooking, or bathing arrangements
Infestations (e.g., fleas, lice, roaches, rodents)
Poor skin condition or skin breakdown (such as rashes, bedsores, or open wounds)
Lack of necessary adaptive aids such as glasses, hearing aids, leg braces walkers etc. or improper medication management
Needed medical and dental care (including the administration of prescribed drugs) not provided
Lack of adequate or appropriate supervision³
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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

Behaviors of Caregivers who may be Abusers

As you interact with caregivers, you should always be on the lookout for certain behaviors that may be indicators that this person is an abuser. Caregiver behaviors to look for include:

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
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 health care providers
Speaks for the person with developmental disabilities
Competes with the person with developmental disabilities
Displays unwelcoming or uncooperative attitude during home visits
Frequently makes attempts to be alone with a particular individual for no apparent legitimate purpose
Common characteristics among those who abuse others include:

Low self-esteem
Mental illness, diminished intelligence, or impaired functioning
Need to control others
Frustration with authority, which can lead to displaced aggression toward weaker persons
History of being abused or neglected as a child
Lack of attachment to the person with the developmental disability ( which can lead to thoughts by the abuser that the person with the developmental disability is not fully human and therefore doesn't feel or hurt in response to their abusive actions)
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Profiles of Abusive Caregivers
Abusive caregivers can usually be classified into one of the following four groups:

Caregivers with limited capacity have a limited ability to understand that their actions may hurt their victims but are unable to distinguish between abusive and non-abusive behaviors. Cultural issues sometimes come into play in these situations. For example, caregivers may interact (or respond to a behavioral issue) with a person with a developmental disability in a way that they themselves were exposed to as a child (even though such methods could be considered abuse in the eyes of the law).

Stressed caregivers may become unable to cope with life stressors and become abusive to persons with developmental disabilities, even though they lack abusive or sadistic intent. It is important to keep in mind that there is never a valid or acceptable reason (including stress) to abuse, neglect, or exploit an individual with a disability.

Batterers (intentional abusers) seek power and control over their victims by any means necessary. Batterers' behavior physically harms, arouses fear, and prevents victims from doing what they wish, or forces them to behave in ways they do not want.

Caregivers with Munchausen Syndrome by Proxy (MSBP) or other Factitious Disorders engage in a pattern of behavior in which they deliberately exaggerate or make up stories and/or cause physical and/or psychological/behavioral/mental problems in order to gain attention. In most cases, the caregiver claims the victim is sick, or actually makes the victim sick, then continually takes the victim for medical treatment, all the while denying knowledge of the real problem.

Types of Emotional Abuse and Neglect

Emotional abuse is the most difficult form of abuse to identify. Even though emotional abuse often happens along with other forms of abuse, it can also occur by itself.

Caregivers who have power and influence over others' lives can use that power to harm or exploit, rather than to support and nurture. This can be especially devastating for children in their developmental years, but it can be harmful for anyone.

Emotional abuse can take the form of threats, insults harassment, and less noticeable forms that are difficult to detect. These can be perpetrated by individuals or by representatives of caregiving systems. Here are some of the most common types of emotional abuse and neglect:

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, necessities, privileges, and opportunities
Denial of ordinary freedoms

Physical Abuse in Caregiving

Sometimes abuse of persons with developmental disabilities takes the form of acts that could be thought of as well-intentioned but unsuccessful attempts by the caregiver to ensure the person's well-being.

In other cases, the abuse is deliberate, and is disguised as caregiving. Here are a few examples of that type of abuse:

Rough physical handling

Sudden movements of bedding

Pushing and pulling

Over-medication

Unnecessary or excessive use of restraints

Ignoring dietary restrictions

Toileting abuse (leaving someone on the toilet too long or not taking them to the bathroom when they need to use it)

Bathing in water that is too hot or too cold

Frightening Physical Actions

Using frightening physical actions that stop short of causing serious physical harm is another form of physical abuse that is too often used by abusive caregivers of people with developmental disabilities. Consider how these actions might affect a person with developmental disabilities:

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

Physical Signs of Abuse: Questionable Bruises

Bruises are among the most common injuries found in children and adults with developmental disabilities who have been abused.

It is important to remember that occasional bruising is also common in people who are not abused, and that people with some disabilities may be prone to bruising for other reasons. Here are some of the more common bruises that may indicate signs of abuse:

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 would appear 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

Other Physical Indicators

The following are some other physical indicators of abuse or neglect of persons with developmental disabilities. In each case, other indicators such as behavior and circumstances must be considered.

Questionable cuts and scrapes

Consider:

Frequent, repetitive, unexplained, or inadequately explained scrapes
Atypical 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 due to inflicted injuries such as whipping
Burns or scalds

Consider:

Patterned burns(e.g., shaped like a cigarette butt or electrical appliance)
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
Bites

Consider:

Human bite marks are easily distinguished from those of animals by their size and shape, and whether flesh is torn.
If bites are explained as self-inflicted, the location and position of the bite must be consistent with the person's functional abilities.
Ligature marks and welts (which could have come from being tied up or gagged)

Could be the result of whipping
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
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

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

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

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

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.

Distinguishing Abuse from Accidental Injury

Accidents happen with everyone, including people with developmental disabilities. The following is a guide to help you tell the difference between accidental and non-accidental injuries. When observing an injury that might be the result of abuse, consider these factors:

Location of the injury:

Certain locations on the body are more likely to sustain accidental injury. These include the knees, elbows, shins, and forehead.
Protected body parts and soft tissue areas, such as the back, thighs, genital area, buttocks, back of legs, or face, are less likely to accidentally come into contact with objects that could cause injury.
Number and frequency of injuries:

The greater the number of injuries, the greater the cause for concern. Unless the person is involved in a serious automobile accident, he/she is not likely to sustain a number of different injuries accidentally. Multiple injuries in different stages of healing are also a strong indicator of chronic abuse.
Size and shape of the injury:

Many non-accidental injuries are inflicted with familiar objects: a stick, a board, a belt, a hair brush. The marks which result bear a strong resemblance to the objects used. Accidental marks resulting from bumps and falls usually have no defined shape.
Description of how the injury occurred:

If an injury is accidental, there should be a reasonable explanation of how it happened that is consistent with the appearance of the injury. When the description of how the injury occurred and the appearance of the injury are inconsistent, there is cause for concern. For example, it is not likely that a person's fall from a wheelchair onto a rug would produce bruises all over the body.
Consistency of injury with the person's developmental capability:

As children grow and gain new skills, their ability to engage in activities that can cause injury increases. A toddler trying to run is likely to suffer bruised knees and a bump on the head. Toddlers are less likely to suffer a broken arm than an eight-year-old who has discovered the joy of climbing trees.
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Behavioral Signs of Abuse

Behavioral signs can be extremely important in detecting abuse and neglect, especially in people who have communication challenges and are unable to tell anyone about what happened to them. In many cases, physical signs of abuse may not yet be present or noticed so behavioral signs are often the first indicators. Usually it is a combination of physical and behavioral changes that are seen in people that have been abused. Here are some of the behavioral signs of possible abuse:

Aggressive behavior

Is widespread among victims of abuse

May imitate the aggression committed against the abused person (e.g., the child who is whipped may whip smaller children)

May generalize to other forms of aggression, such as yelling or hitting others

May be exhibited through excessively violent drawings, stories, or play

Atypical attachment

Consider:

Children who have been abused often appear insecure with strangers, and compulsively seek the presence and attention of their primary caregivers, yet may express little affection towards them

A preschooler may cling to his mother and cry excessively both when she leaves him and when she returns

The person who has been abused may be uncomfortable with physical contact with anyone

Disclosure
Direct disclosures of abuse, neglect, or exploitation are powerful evidence, even when some details are incorrect.

Complaining of soreness or pain when unrelated to disability or illness.

All disclosures should be given attention and referred to the appropriate authorities for full evaluation.

Fearfulness
Victims of abuse often appear fearful of others:

Fear can be specific to the abuser, but may generalize to other people or places

Fear may be age or gender-specific (e.g., the child who turns away and raises his or her arms as if to ward off a blow whenever an adult nearby makes a sudden move)

The person may be afraid to go home, or afraid to leave home

The child may be afraid to change clothes for gym activities (may be attempting to hide injuries, bruises), or may be afraid to take off a long-sleeved shirt even in the heat

Learning Disabilities
Difficulty learning can be a result of abuse for complex reasons. Much of the child's energy is directed toward surviving the abuse and coping with stress. This leaves little energy for learning or other typical childhood activities.

Psychotherapy, or other appropriate treatments, can lead to improvement for those whose learning disabilities resulted from their psychological response to abuse.

Noncompliance
People who are abused often become noncompliant. Noncompliance:

May be a generalized response to frustration, or an effort to gain personal control

May be aimed at avoidance of the abuser or the abusive situation

Can take the form of chronically running away (adolescents)

Regression
Often children who are abused behave like younger children. This form of regression:

May reflect their inability to move through normal stages of development in the face of intense anxiety

Could reflect a mechanism of escape

Can be limited to affective and interpersonal behavior

Can extend to developmental skills such as toileting (e.g., a child who was previously toilet trained may begin to have accidents after experiencing abuse)

Sleepdisturbance
Having nightmares or trouble getting to sleep are characteristic of abused persons

This can lead to further abuse due to caregiver frustration and loss of sleep

Withdrawal
People who are abused often withdraw from others and spend much of their time alone

Sometimes the withdrawal is related to depression

Sometimes the person will alternate between withdrawal and aggression

Aggression may be the person's way of discouraging interaction with others. For example, an abused child may keep to himself and avoid other children, but become aggressive when unable to avoid interaction

Signs and Symptoms of Exploitation

Taking advantage of individuals with a developmental disability can rob them of their independence and the ability to afford the basic necessities of life, such as food, rent payments and medicine. It's also a crime and should be reported right away to the Florida Abuse Hotline.

In particular, financial exploitation often goes unreported or is reported long after the damage is done. When that happens, the suspect is far more likely to get away with the crime and move on to other victims. Here are a few signs to watch for:

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

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 anybody 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

Lack of money early in the month (when disability or other types of government benefits are paid)

If you notice any of these signs or suspect that a person with a developmental disability might be a victim of exploitation, please contact the Florida Abuse Hotline immediately.

Factors That Make it Hard to Recognize Abuse, Neglect, and Exploitation

A number of factors can make it difficult to identify abuse, neglect, and exploitation of persons with developmental disabilities.

Person does not recognize abuse, neglect, or exploitation. In order to let someone know they are being maltreated, victims of abuse must:

Recognize the behavior as abusive

Consider it significant enough to report

Be able to communicate to someone about the abuse

Be believed

"I wasn't able to say, "knock it off" to my family who was doing my personal care. I thought it was normal to be tossed around in my chair. To have a comb dragged through my hair so it comes out. To be left on a toilet for an hour. It took me about five years of hiring people, when I realized that I didn't have to accept those things."

Many people with developmental disabilities have grown accustomed to being treated without respect, and are used to routine treatment that most other people would not tolerate. People with developmental disabilities may view only the most severe acts against them to be worthy of attention and possible reporting. The victim may consider an incident "unimportant" unless it involves serious physical harm.

Greater personal assistance needs
Some people with physical disabilities require help with personal care routines such as dressing and bathing throughout their lives. Personal care routines require physical contact, and may result in occasional touching of sexual parts of the body, with the result that the person can't tell whether these touches are accidental, required, or abusive.

Fear of not having needs met
People with developmental disabilities who are dependent on others for their day-to-day care may be fearful that if they let anyone know they are being mistreated, they will no longer receive the care they need. They may also fear reprisals from their caregivers if they tell anyone.

Communication challenges
Some people with developmental disabilities are limited in their ability to communicate verbally about an abusive incident. Adaptations may be required to insure adequate communications. Behavioral and circumstantial indicators become more important in identifying abuse, neglect, and exploitation in these cases.

Self-abusive behaviors
Some people with developmental disabilities resulting in behavioral or cognitive impairments engage in self-abusive behaviors, or are prone to accidental injury. This makes it more difficult to identify abuse, neglect, or exploitation when it occurs for these persons.

Signs of abuse may be interpreted as behavioral problems

The best rule of thumb for recognizing the behavioral signs of abuse, neglect, or exploitation is to know what is normal behavior for the particular person. When assessing the person's behavior, it is important to take the following steps:

Examine the history of the behavior

Obtain a behavioral baseline

Determine whether there has been a clear behavior change that has taken place during the time frame in question

Consider any changes in the intensity and duration of the behavioral episodes

The Problem with "Subtle" Abuse

"If they're (personal assistants are) feeling angry for some reason…at you or whatever, they might set you down in your chair a little harder than normal. Or…position you in a little rougher way. And you sit there thinking, 'Now did he mean to do that?' It's really hard to distinguish. It makes you question yourself a lot."

While some actions (such as punching) are easy to identify as abuse, other forms of mistreatment by caregivers are harder to spot (although they still represent acts of abuse). Below are examples of what can be termed "subtle" abuse:

Ignoring a person when they ask for help

Making a person beg for help

Providing help in a way that makes the person feel like a burden or feel guilty

Intentionally making a person wait for help

Refusing to recharge the battery of a person's wheelchair

Providing physical care in a way that is unnecessarily rough or careless

Refusing to provide help unless the person agrees to lend money

Purposely unplugging or turning off adaptive equipment

Conditions of People with Developmental Disabilities That Can Sometimes Look Like Abuse or Neglect

There are a number of conditions that may lead you to incorrectly think that someone with a developmental disability has been abused or neglected. Here are some of the most common:

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: Some people with different kinds of disabilities may be overly sensitive to touch, textures, taste, or temperature. These persons may resist hugs, face washing or other harmless/innocent types of touch. This can also look like failure to thrive or significant behavioral problems.

Mongolian spots: Mongolian spots which are bluish or bruised-appearing areas that are usually seen on the lower back or buttocks. These spots are harmless and occur more commonly in persons of color. They may remain for months or years.

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