Adult protection & people with intellectual disabilities: Exploring their multiple vulnerabilities

1. Adult protection &people with intellectual disabilities: Exploring their multiple vulnerabilities Improving the quality of life for people with learning disabilities: Research into practice James Hogg, University of Dundee

2. (Friday May 7 2004) yielded many examples to support this statement: Scotsman, p.1 Rumsfeld under fire over new torture images Scotsman p.1 Council rocked by fresh claims of abuse: (report by Social Work Services Inspectorate and the Mental Welfare Commission on victimization and abuse of people with learning disabilities in Scottish Borders Region) Guardian, p.7 Pastor faces jail for sex assaults: Former church head preyed on vulnerable female worshippers Scotsman p.8 Two sentenced to total of nine years’ detention after racist attack Guardian, p.11 Sex offender banned from contact with children Guardian, p.14 Nigerian Muslims bury 600 after Christian slaughter Scotsman, p.17 UN a factor in trafficking of women, Kosovo report says: (enforced prostitution of over 2000 women) Guardian p.17 Village council ‘approved rapes’ (in Pakistan landlord permitted to rape the sister and sister-in-law of a man accused of an illicit relationship with his daughter) A day in the life of………….

3. ..and another day………. • Joanne Nelson • Marion Edgington • Anthony Sawoniuk • Leah Mates • Joe Chillemi Guardian 8 November 2005

4. The concept of the vulnerable adult Scottish Law Commission (1997) Wide definition: • “…capable of being wounded, liable to injury or hurt to feelings: open to successful attack: capable of being persuaded or tempted…" • Narrow definition: “…an adult (aged 16 or over) who is unable to safeguard his or her personal welfare, property, or financial affairs, and is: in need of care and attention arising out of age or infirmity, or suffering from illness or mental disorder, or substantially handicapped by any disability.”

5. The concept of the vulnerable adult The concept of vulnerable adult should be applied to a person who: “…is, or may be, in need of community care services by reason of mental or other disability, age or illness, and who is or may be unable to protect him or herself against significant harm or exploitation.” Department of Health (2000) No Secrets: The protection of vulnerable adults. London: Department of Health.

6. The concept of the vulnerable adult “…accommodation, and nursing or personal care, are provided in a care service; personal care is provided in their own home under arrangements made by a domiciliary care agency; or prescribed services are provided by an NHS Board, or an independent hospital, independent clinic or an independent medical agency, or National Health service body that is registered under the Care Commission.” Scottish Executive (2004)

7. What constitutes abuse? Victimising and abusive behaviour includes: • physical abuse • sexual abuse • emotional abuse • financial abuse • neglect ……… of an individual who has not given, or is incapable of giving, informed consent to the transaction.

8. A model of abuse • Characteristics of the individual • Characteristics of the potential or actual perpetrator • The relationship between the victim and perpetrator • Environmental factors Nettlebeck, T., Wilson, C., Poter, R. & Perry, C. (2000) The influence of interpersonal competence on personal vulnerability of persons with mental retardation. Journal of Interpersonal Violence, 15, 46-62.

9. A general definition: Thus, a vulnerable adult is an individual 16 years of age or over who is, due to personal characteristics, vulnerable to a potential perpetrator of abuse, and is in such a relationship with that person and in such a setting, that the probability of physical, sexual, emotional and/or financial abuse and neglect is significantly increased.

10. A model of abuse: Direct effects of disability • Characteristics of the individual • incapacity to avoid or escape from the situation • inappropriate decision making regarding what is appropriate or acceptable • Attractive victim • victim precipitation • gullibility? credulity?

11. A model of abuse Socially mediated effects of disability Characteristics of the person who may be abused: • failure to teach the person behaviour that will decrease victimization • may have been taught to be passive and compliant rather than assertive • may be sexually uneducated instead of being knowledgeable about sexuality and sexual behaviour • more subtle distortion of an individual’s psychosexual development

12. An ecological model of abuseThe perpetrator • Two types: • Predatory • Corrupt • Gender • Psychological dimensions: • Retributive • Abuse reactive

13. A model of abuse The relationship between the victim and perpetrator • Power imbalance • Coercion • Dependency

14. A model of abuseEnvironmental factors • Nature of care activities • Closed environment – opportunity • Service sub-culture • Absence of procedures to preclude and respond to abuse • Inadequate screening of staff

15. What proportion of people with intellectual disabilities have been abused? • there is a consensus that adequate research to specify precisely what this difference is lacking • definition of the problems in defining abuse, and in collecting the relevant data, lead to widely differing figures in different studies • same conclusion applicable to elderly people and those with mental health problems

16. Who are the abusers? • Family member • Paid staff • Other people with intellectual disabilities • Other people known to the abused individual • Other people not known to the abused individual

17. What are the consequences of abuse for perpetrators? 18 of 26 cases referred to police: • 4 staff members were arrested and interviewed. None were prosecuted • family members, 3 were interviewed but not proceeded against • 2 members of the public were arrested but not proceeded against 1 because the victim would not pursue the allegation and one because lack of consent could not be demonstrated • 3 cases of service users being perpetrators the police were not involved • there were no court cases as a result of this process with the most typical decision being to monitor the situation Joyce, T.A. (2003) An audit of investigations into allegations of abuse involving adults with intellectual disability. Journal of Intellectual Disability Research, 47, 606-616.

18. What are the consequences of abuse for the abused? • bruising, cuts, broken bones, burns, head injury, dehydration and malnutrition • sleeping difficulties, stomach problems, breathing problems or confusion • anxiety, depression and peri-menstrual symptoms in women • mental health and behavioural consequences

19. Scottish Executive Response to Adult Protection • Pre-legislative consultation process • New duties & powers conferred on public authorities • Establishment of Multi-agency Adult Protection Committees to manage adult protection policies, systems and procedures at local level • “The List” – people unsuitable to work with vulnerable adults

20. The Scottish Child Protection Review: Aims • Explored the effectiveness of the Scottish child protection framework with respect to: • Describing practice with respect to child protection • Evaluating of the quality of child protection practice Daniel, B. (2003) The Scottish Child Protection Review: Development of a methodology for a national multidisciplinary audit of child protection Practice. Qualitative Social Work, 2, 435-456.

21. The Scottish Child Protection Review:Methods Case study methodology • Case file scrutiny • Interviews with relevant personnel • Agency evaluation • Overall evaluation

22. The Scottish Child Protection Review: Outcome Successful outcome of this study provides a procedurally firm and valid base on which to develop a parallel methodology to investigate adult protection procedures in Scotland.

23. Scottish Adult Protection Study: Aims 1 • Investigate practice with respect to the protection of adults subject to victimization and abuse in the light of inter-agency procedures and through the development of an agreed protocol that reflects best practice • infer from this investigation the quality of practice as it impacts on individual adults’ physical and mental health and general well-being

24. Scottish Adult Protection Study: Aims 2 • To determine for a limited number of cases the ecological context of the victimization and abuse in the light of recent models of victimisation and abuse discussed earlier • To provide a baseline, and pilot a methodology, to monitor impact of Scottish Executive legislation

25. Scottish Adult Protection Study: Scope Adults: • With intellectual disabilities • Elderly people • With mental health difficulties

26. Scottish Adult Protection Study: Respondents At least the following involved: • Social work • Nursing • Medical (GP, specialist) • Police • Voluntary organisation

27. Age Concern Scotland (2004) Interagency Procedures for the Protection of Vulnerable Adults. Edinburgh: Age Concern Scotland. • This document has been selected to guide the research because it: • is research-based • has been developed through an interagency, practitioners’ working group • took account of failures in practice • took account of existing and future possible legislation and agency responsibilities

29. Neglect as abuse: “Avoidable deaths” • Under-diagnosis and delayed or absent treatment of medical conditions leading to avoidable deaths[Janicki et al 2002; Mencap 2004 –”Treat me right!”] • High prevalence of external causes of death among people with intellectual disabilities [Strauss et al 1998] • Inadequate screening programmes [Cancer; Davies & Duff 2001] helicobacter pylori[Wallace et al 2002]

30. Positive & negative abuse • Systemic issues for intra- and interagency working • Care staff in social and health settings need to be made more aware of risks, responses to signs and symptoms and monitoring of special incidents • Enhanced awareness of spectrum of positive and negative abuse among people with intellectual disabilities