PowerPoint Presentation

TEACH-VIP

T rainin= g,

E ducating,

A dvancing

C ollaboration in

H ealth on

V iolence and

I njury

P revention =

Core curriculum

Lesson 12

= The materials in this lesson are based on an injury prevention and control curriculum originally = developed by the World Health = Organization and a global network = of injury experts.&#= 13;

Gen= eral lesson description

This s= ection explores the abuse and neglect of children and the elderly. It explains t= he global burden of these types of violence as well as the determinants and = risk factors related to violence against these groups of individuals. Potential strategies for obtaining information and controlling or preventing these types of violence are taught by means of examples from the literature. Ba= sic information on legal and forensic implications for these types of violenc= e is provided. It addresses important recommendations for reducing both the ab= use and neglect of children and the elderly.

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Injury prevention and control strategies for child abuse and neglect Abuse = and neglect of children and the elderly

Lesson 12

Sessi= on time: 60 minutes

Secti= on V. Applied injury prevention and contr= ol, and safety promotion

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Main objectives of this lesson&= #13;

1. To introduce students to the study, prevention and control of injuries related to the abuse

    and neglect of childr= en and the elderly.

2. To explore measures taken at globa= l, regional and national levels to control and prevent

&nbs= p; violence against children and the elderly.

Core competencies that students= should attain by the end of the session

1. Understand the nature and conseque= nces of acts of abuse and neglect of children and the

    elderly. <= /div>
2. Be aware of risk factors associate= d with these two forms of violence.

3. Understand the issues relating to = the prevention of abuse and neglect of children and the

    elderly.&= #13;

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Child and elder abuse

and neglect

TEACH-VIP

This l= esson addresses some important factors and characteristics associated with the perpetration of violence against two vulnerable populations, children and= the elderly.

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Intentional injuries: children =

Definition of child abuse:

All forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation resulting in actua= l or potential harm to the child’s health, survival, development or digni= ty in the context of a relationship of responsibility, trust, or power.

In 199= 9, the WHO Consultation on Child Abuse Prevention drafted the following definition:<= /font>

Child = abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial= or other exploitation resulting in actual or potential harm to the childR= 17;s health, survival, development or dignity in the context of a relationship= of responsibility, trust, or power.

This d= efinition in a broad sense covers acts by parents or caregivers that result in harm to t= he child. This harm can be physical, psychological, sexual or a consequence = of neglect or deprivation (1), and would include inadequate health care and medical neglect.

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Types of child abuse

<= span style=3D'font-family:Arial;font-size:133%'>• Physical abuse <= /div>
<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Child sexual abuse

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Neglect and negligent treatment= 3;

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Emotional abuse

Physic= al abuse refers to physical or bodily harm, or the potential for that, caused to children by their caregivers.

Sexual= abuse is defined as acts where the child is used to sexually gratify the caregiver= .

Emotio= nal abuse refers to the failure of a caregiver to provide a supportive environment = and includes acts such as restrictions of mobility, denigration, ridicule, threats and intimidation, discrimination and other forms of non-physical rejection.

Neglec= t or negligent treatment refer to the failure of caregivers to provide a supportive environment for the child, although parents are in a position to do so, a= nd includes areas of health, education, emotional development, nutrition, shelter and safe living conditions.

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Types of physical punishment&#= 13;

Severe physical punishment

• hit the child with an o= bject (not on the buttocks)

<= span style=3D'font-family:Arial;font-size:75%'>• kicked = the child

<= span style=3D'font-family:Arial;font-size:75%'>• burned = the child

<= span style=3D'font-family:Arial;font-size:75%'>• beat the child

<= span style=3D'font-family:Arial;font-size:75%'>• threate= ned the child with a knife or gun

<= span style=3D'font-family:Arial;font-size:75%'>• choked = the child

Moderate physical punishment =

<= span style=3D'font-family:Arial;font-size:75%'>• spanked buttocks (with hand)

<= span style=3D'font-family:Arial;font-size:75%'>• hit the= child on buttocks (with object)

<= span style=3D'font-family:Arial;font-size:75%'>• slapped= the child's face or head

<= span style=3D'font-family:Arial;font-size:75%'>• pulled = the child's hair

<= span style=3D'font-family:Arial;font-size:75%'>• shook t= he child

<= span style=3D'font-family:Arial;font-size:75%'>• hit the= child with knuckles

<= span style=3D'font-family:Arial;font-size:75%'>• pinched= the child

<= span style=3D'font-family:Arial;font-size:75%'>• twisted= the child's ear

• forced the child to kne= el or stand in an uncomfortable position

• put hot pepper in the c= hild's mouth

WorldSAFE study

Global= estimates suggest that infants and very young children are at greater risk of fatal abuse than children aged 5-14 years. In most places however there are high levels of misclassification as deaths that are infanticide are classified= as due to other causes (1).

Data o= n non-fatal abuse comes from several sources. Official statistics are not very useful because legal and cultural variability in the definitions of child abuse = make data difficult to compare. Population-based surveys are probably a more accurate source of information.

Physic= al abuse varies substantially as shown in the table above. Physical punishment is = not limited to the home in many cases and extends to the school and other institutions.

Sexual= abuse estimates also depend on the definitions used and who is included. Estima= tes vary substantially in surveys depending on whether caregivers, peers or no physical contact are included in the definition.

Emotio= nal and psychological abuse has been even less studied although shouting and thre= ats appear to be the most common forms used.

Defini= tions of neglect vary also by country but appear to be more common than other form= s of abuse.

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Risk factors
<= span style=3D'font-family:Arial;font-size:133%'>• Individual child-related factors&#= 13;

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

• Caregiver and family characteristics

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Community factors

The mo= st common individual factors that increase a child’s vulnerability for abuse = are:

age

as men= tioned before younger children and infants tend to be at higher risk of physical abuse;=

sexual= abuse rates tend to be higher in puberty;

sex

female= s are usually more frequently victimized than males (up to three times more);

while = most forms of abuse and neglect are directed towards females, harsh physical punishment seems to be more frequent against males.

Also p= remature infants, twins and handicapped children are at higher risk of being abuse= d. However these latter characteristics are less important than parental or societal factors.

One of= the most important risk factors is a non-biological relationship between the abuser and the child, often the mother’s partner.

Unempl= oyment, low socio-economic status, low education levels and substance abuse are also notable risk factors for child abuse.

Female= s inflict more violence in general but males inflict more life threatening violence. Men more commonly perpetrate sexual abuse.

Other = risk factors include overcrowding, parental low self-esteem and impulsivity, caregiver history of being abused, current violence in the home, stress, health problems and job loss.

At the= community level other risk factors are poverty, high population turnover and overcrowding, social isolation of family unit from the community and lack= of social support systems for the family. Societies with high levels of inequality and no social protective policies for children are at higher r= isk of presenting abuse. Conflict and war also increase likelihood of abuse (= 1).

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<= span style=3D'font-family:Arial;font-size:133%'>• Physical

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Sexual and reproductive

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Psychological

Consequences Among = the physical consequences of abuse common ones are lacerations, fractures, bruises, br= ain or nervous system injuries, burns and intra-abdominal injuries.
Sexual= and reproductive consequences include sexual dysfunction, sexually transmitted infections and unwanted pregnancy.
Psycho= logical factors include cognitive impairment, substance abuse, developmental dela= ys, depression, anxiety, eating and sleeping disorders, hyperactivity, poor self-esteem, suicidal behaviour and post-traumatic stress disorder.

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<= span style=3D'font-family:Arial'>• Training in parenting=

<= span style=3D'font-family:Arial;visibility:hidden'>•

<= span style=3D'font-family:Arial'>• Home visitation <= /span>

<= span style=3D'font-family:Arial;visibility:hidden'>•

<= span style=3D'font-family:Arial'>• Therapy and services = for victims of CAN

<= span style=3D'font-family:Arial;visibility:hidden'>•

<= span style=3D'font-family:Arial'>• Treatment programmes = for perpetrators

<= span style=3D'font-family:Arial;visibility:hidden'>•

<= span style=3D'font-family:Arial'>• Legal measures

<= span style=3D'font-family:Arial;visibility:hidden'>•

<= span style=3D'font-family:Arial'>• Community-based activities

<= span style=3D'font-family:Arial;visibility:hidden'>•

<= span style=3D'font-family:Arial'>• Use of the media

Prevention

Some a= pproaches with promising results are included below.

Traini= ng in parenting: education on child development and skills in managing children= .

Traini= ng of health care professionals in identification and management of child abuse proble= ms.

Home v= isitation: providing information and support for care of children as well as parental training.

Servic= es for victims of Child Abuse and Neglect (CAN): Screening of abuse by health-care professionals and training of health-care professionals on how to detect = and refer potential cases of abuse. Other therapeutic approaches include day = care treatments, stimulation of communication to reduce isolation and other treatments for conditions related to sexual abuse. Other services are directed to children who witness abuse or to adults who where abused as children.

Legal = measures include the development or strengthening of child protection services, the creation of child fatality review teams, strengthening of arrest and prosecution policies, and mandatory treatment of offenders.

Effort= s within the community include school programmes that teach children how to identify threatening situations.

Advoca= cy interventions are intended to increase community awareness and educate the public about the problem.

At a societal level the strengthening of prevention policies can foster the development of community, health and legal interventions.

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Policy recommendations

• = Better assessment and treatment of abuse

•<= /span> <= /div>
• = Improved response systems

•<= /span> <= /div>
• = Policy development aimed at prevention

•<= /span> <= /div>
• = Improved data

•<= /span> <= /div>
• Increased research on: =

=        - disciplinary practices, neglect, risk factors,

   effective prevention interventions

=

• = Improved training efforts

Public= health efforts should therefore be concentrated in the following areas (1).

Improv= ing the monitoring and assessment techniques for child abuse; developing or strengthening response systems which need to integrate health, educational and legal components; setting up mandatory reporting; prosecuting abusers; improving capacity of health professionals to detect and refer potential cases; and coordinate these referrals with appropriate actions by the jus= tice system.

Improv= ing the scope and nature of the data obtained to describe the problem, increasing resea= rch efforts aimed at evaluating interventions or developing new ones, address= ing the issues of neglect and risk factors.

Traini= ng professionals to look for and deal with potential cases of abuse.<= br>

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Intentional injuries: older persons

Definition of elder abuse:

Elder abuse can be defined as “a single,= or repeated act, or lack of appropriate action, occurring within any relation= ship where there is an expectation of trust which causes harm or distress to an older person”.

Anothe= r vulnerable population is the elderly.

Abuse = and neglect of the elderly has been defined as (1, 2):

A sing= le, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person”.

Howeve= r, there is no universally agreed or standardized definition as yet.

An alt= ernative definition is (3): “abuse is a violation of an individual's human a= nd civil rights by any other person or persons”.

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Types of elder abuse

•<= /span> Physical abuse =

• =

•<= /span> Psychological/emotional abuse =

• =

•<= /span> Financial/material abuse

• =

•<= /span> Sexual abuse
• =

•<= /span> Neglect

• =

•<= /span> Discriminatory

Abuse = of the elderly includes:

physic= al abuse – the use of physical force that may result in bodily injury, physi= cal pain, or impairment;

psycho= logical abuse – the infliction of anguish, pain, or distress through verbal or nonverbal acts;

sexual= abuse – non-consensual sexual contact of any kind with an elderly person, or sexu= al contact with any person incapable of giving consent;

neglec= t – the refusal or failure to fulfil any part of a person's obligations or=

duties= to an elderly person, this may include intentional neglect or unintentional neglect due= to ignorance or inexperience;

financ= ial or material abuse – the illegal or improper use of an elderly person's funds, property or assets;

discri= minatory abuse – ageism, racism.

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Global burden

Abuse = of the elderly can exist in domestic or institutional settings.

There = is a concern that the magnitude of the problem of elder abuse may be increasing as this sector of the global population is undergoing a marked increase. By the y= ear 2025, the population older than 60 years will be 1.2 billion or double th= at of 1995 and about 80% of these will be in the developing world.

The st= ructure of families is also changing and increased mobilization is deteriorating fam= ily support systems. Additionally only 30% of the world’s elderly are covered by some type of pension scheme thus highlighting the lack of government social support for this population.

Given = the lack of official sources, information on the extent of the problem has largely re= lied on surveys. A large number of these report a prevalence of about 4–= 6%.

Abuse = is usually physical but also appears in the form of sexual and financial abuse. Psychological forms of abuse may also be relatively high and can be more difficult to identify. Most surveys report no significant differences by = age and sex. Many surveys indicate that women are more likely to be abused th= an men, and their experience is likely to be of the more serious forms of ab= use.

Survey= results suggest that physical and psychological abuse is higher in institutional settings than in home settings.

The di= fficulty of identifying cases of neglect makes it likely that the problem of elder ab= use is currently underestimated.

Howeve= r, there is a limited research base, especially in terms of incidence and prevalence. Little research has emerged from lower income countries; the research bas= e is almost exclusively from higher income countries.

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Risk factors
<= span style=3D'font-family:Arial;font-size:133%'>• Individual

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Relationship
<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Community

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

<= span style=3D'font-family:Arial;font-size:133%'>• Society

Elder = abuse, like other types of domestic violence, is extremely complex. Generally a combination of psychological, social, and economic factors, along with the mental and physical conditions of the victim and the perpetrator, contrib= ute to the occurrence of elder maltreatment (4).

Some p= ossible risk factors for elder abuse are:

relati= onship with abuser – spouse, dependant adult children

physic= al and cognitive impairments

strain= ed family relationships

caregi= ver stress.

At the= community level, social isolation is an important factor for mistreatment and may be either a cause or a consequence of abuse.

At the= societal level, depiction of the elderly as frail, weak or dependent can facilitate situations of abuse or exploitation.

Other = elements include the erosion of intergenerational bonds, systems of inheritance wh= ere women or men are discriminated against, migration of younger population t= hat erodes family ties and loss of a role in society for the elderly.<= br>

Who ar= e the abusers?

It has= been estimated that roughly two thirds of all elder abuse perpetrators are fam= ily members, most often the victim’s adult child or spouse. Abusers in = many instances are financially dependent on the elder’s resources and ha= ve problems related to alcohol and drugs.

In cou= ntries where three or more generations live together it may be necessary to consider t= he intergenerational nature of violence.

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<= span style=3D'font-family:Arial;font-size:133%'>• Domestic settings

<= span style=3D'font-family:Arial;font-size:133%;visibility:hidden'>•<= /span> =

• Institutional settings

Consequences Based = on surveys conducted on populations, higher proportions of the elderly that are abus= ed suffer from depression and anxiety when compared to non-abused population= s. Other feelings include shame, guilt, alienation and helplessness. Some longitudinal studies have shown that stress due to abuse can be a serious contributing factor for premature death.
Other = consequences include physical injury (which can be more severe than in other age group= s), gastrointestinal disorders, chronic pain syndromes, sexually transmitted diseases, depression and suicidal thoughts or behaviour.
In ins= titutional settings abuse can occur because of inadequate care, problems with staffi= ng, poor environmental conditions and inadequate institutional policies. Much institutional abuse occurs in settings with unquestioned regimentation and exploitation of dependence. There is a long history of advanced welfare systems being unable to prevent institutional abuse.
In ins= titutional settings abuse can involve deficiencies in food preparation, poor assessm= ent of health care needs, injuries, pressure sores, quality of care, physical restraints, housekeeping deficiencies and lack of dignity. These types of problems have been reported in institutions regardless of the type of advertised quality of care.

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Indicators

• Indica= tors relating to the elderly person

- physical

- behavioural and emotional

- sexual

- financial

<= span style=3D'font-family:Arial;font-size:117%'>• Indica= tors relating to the caregiver

There = are many indicators of elder abuse relating to either the elderly or the caregiver= .

The el= derly may show consequences of abuse at the physical, behavioural or emotional, sexual or financial levels (1).

Physic= al indicators include:

compla= ints of being physically assaulted

unexpl= ained falls and injuries

burns = and bruises in unusual places or of an unusual type

cuts, = finger marks or other evidence of physical restraint

excess= ive repeat prescriptions or under-usage of medication

malnou= rishment or dehydration without an illness-related cause

eviden= ce of inadequate care or poor standards of hygiene

person= seeks medical attention from a variety of doctors or medical centres.

Behavi= oural and emotional indicators include:

change= in eating pattern or sleep problems

fear, = confusion or air of resignation

passiv= ity, withdrawal or increasing depression

helple= ssness, hopelessness or anxiety

contra= dictory statements or other ambivalence not resulting from mental confusion

reluct= ance to talk openly

avoida= nce of physical, eye or verbal contact with caregiver

older = person is isolated by others.

Sexual= indicators include:

compla= ints of being sexually assaulted

sexual= behaviour that is out of keeping with the older person's usual relationships and previous personality

unexpl= ained changes in behaviour, such as aggression, withdrawal or self-mutilation

unusua= l sexual behaviour

freque= nt complaints of abdominal pain, or unexplained vaginal or anal bleeding

recurr= ent genital infections, or bruises around the breasts or genital area

torn, = stained or bloody underclothes.

Financ= ial indicators include:

withdr= awals of money that are erratic, or not typical of the older person

withdr= awals of money that are inconsistent with the older person's means

changi= ng a will or property title to leave house or assets to "new friends or relatives"

proper= ty is missing

older = person "can't find" jewellery or personal belongings

suspic= ious activity on credit card account

lack o= f amenities, when the older person could afford them

untrea= ted medical or mental health problems

level = of care not commensurate with the older person’s income or assets.

Indica= tors in the caregiver may include:

caregi= ver appears tired or stressed

caregi= ver seems excessively concerned or unconcerned

caregi= ver blames the older person for acts such as incontinence

caregi= ver behaves aggressively

caregi= ver treats the older person like a child or in a dehumanized way

caregi= ver has a history of substance abuse or abusing others

caregi= ver does not want the older person to be interviewed alone

caregi= ver responds defensively when questioned – may be hostile or evasive

caregi= ver has been providing care to the older person for a long period of time.

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=

• Social services

- availability of medical, legal, financial

support networks = ;

- emergency shelters

- telephone help lines

=

• Health care

     - detection of = signs of abuse

- provision of adequate referral services

Prevention

Effort= s to control or prevent elder abuse have been mainly applied in high-income countries. Between countries, there are differences in the level of implementation of programs or acknowledgement of the problem.

Most r= esponses to this type of abuse incorporate activities between social services, health care and legal systems. Additionally, many programmes have been developed within contexts of prevention of violence within the family. From the perspective of social services the availability of medical, legal and financial support networks is the key for establishing prevention activit= ies. Other services include the creation of emergency shelters and the use of telephone help-lines to report or refer cases of abuse.

There = is also a need to screen caregivers, assign motivation and suitability to provide effect= ive and humane care. Educating caregivers to identify their own early warning signs of anger or dissatisfaction with caregiving may also help to avoid = an abusive situation.

In som= e lower-income countries, with less social support, self-help groups have been establish= ed to confront the problem. In some countries in Latin America, Europe and Australia, the health care sector has played an important role. In other countries participation of medical professionals has been less.

There = is a need for the prompt identification of abuse cases through early signs of abuse and= the provision of adequate referral services.

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•<= /span> Legal actions

=

• Education and public awareness<= /span> <= /div>
     - inform commun= ity of types of abuse

and signs of abuse
- media campaigns

- raise aware= ness among older people

providing information on services=

Prevention

Other = important elements for prevention involve the development and passing of laws aimed= at protecting the elderly. Even when these laws exist there is a need to fos= ter appropriate responses that include ethical, cultural and professional factors.

Inform= ing the community about the types of abuse and the signs of abuse is an important element supporting prevention.

Other = techniques that have been used include the use of media campaigns and a more direct approach of increasing awareness among the elderly providing information = on services and referral systems.

Zero t= olerance campaigns have been helpful in addressing domestic violence in the United Kingdom and the United States. Such an approach may also be applicable to= the elder abuse problem.

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Policy recommendations

•<= /span> Improved knowledge about the probl= em <= /div>
- on causes of abuse

- impact of abuse

- effect of interventions

•<= /span> <= /div>
• Strengthening of laws and policies= <= /div>
     - strengthening= of basic rights

- addressing = and changing abusive traditions

•<= /span> <= /div>
•<= /span> Identification of more effective prevention strategies

Curren= tly, there are gaps in our knowledge of causes and risk factors for abuse and additional research is needed. Similarly, there is a need to know more about the imp= act of abuse on different populations and to conduct rigorous evaluation of preventive measures to determine which are the most effective.

There = is also the need, by legal means, to strengthen the basic rights of people and address and change abusive traditions.

The to= pic of elder abuse is just beginning to be discussed or even recognized in some settin= gs and many lessons learned from other areas of violence prevention can bene= fit the promotion of more integrated actions for elder abuse.

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General lesson description =
This section explo= res the abuse and neglect of children and the elderly. It explains the global burden of these typ= es of violence as well as the determinants and risk factors related to violence against these gro= ups of individuals. Potential strategies for obtaining information and controlling or <= span lang=3DEN-GB style=3D'font-family:Arial;mso-ascii-font-family:Arial;mso-bi= di-font-family: Arial;mso-hansi-font-family:Arial'>preventing these types of violence are taught by means of examples from the literature. Basic information on legal and forensic implications for these types of violence is provided. It addresses important recommendations for reducing both the abuse and neglect of children and the elderly.

This lesson addresses some important factors and characteristics associated with the perpetration of violence against two vulnerable populations, children and the elderly.

In 1999, the WHO Consultation on Child Abuse Prevention drafted the= following definition: Child abuse or maltreatment constitutes= all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatme= nt or commercial or other exploitation resulting in actual or potential harm to the child’s health, survival, develop= ment or dignity in the context of a relationship of responsibility, trust, or power. This definition in a broad sense covers acts by parents or caregivers that result in harm to the child. This harm can be physical, psychologic= al, sexual or a consequ= ence of neglect or deprivation (1), and would include inadequate health care and medical negl= ect.

Physical abuse refers to physical or bodily harm, or the potential = for that, caused to children by their caregivers. Sexual abuse is defined as acts where the child is used to sexually gratify the caregiver. Emotional ab= use refers to the failure of a caregiver to provide a supportive environment and includes acts such as restrictions of mobility, denigration, ridicule, threats and intimidation, discrimination and other forms of non-physical rejection. Neglect or negligent treatment refer to= the failure of caregivers to provide a supportive environment for the child, although parents are in a position to do so, and includes areas of health, education, emotional development, nutrition, shelter and safe living conditions.

Global estimates suggest that infants and very young children are at greater risk of fatal abuse than children aged 5-14 years. In most places however there are high levels of misclassificat= ion as deaths that are infanticide are classified as due to other causes (1). Data on non-fatal abuse comes from seve= ral sources. Official statistics are not very useful because legal and cultural variability in the definitions of child abuse make data difficult to compare. Population-based surveys are = probably a more accurate source of information. Physical abu= se varies substantially as shown in the table above. Physical punishment is not limited to the home in many cases and extends to the school and other institutions. Sexual abuse estimates also depend on t= he definitions used and who is included. Estimates vary substantially in surveys depending on whet= her caregivers, peers or no physical contact are included in the definition. Emotional and psychological abuse has been even less studied althou= gh shouting and threats appear to be the m= ost common forms used. Definitions of neglect vary also by country but appear to be more common than other f= orms of abuse.

The most common individual factors that increase a child’s vulnerability for abuse are:

age

as mentioned before younger children and infants tend to be at higher risk of physical abuse;

sexual abuse rates tend to be higher in puberty;

sex

females are usually more frequently victimized than males (up to three times more);

while most forms of abuse and neglect a= re directed towards females, harsh physical punishment seems to be more frequent against males. <= /span>

Also premature infants, twins and handicapped children are at higher risk of being abused. However these latter characteristics are less important than parental or societal factors.

One of the most important risk factors = is a non-biological relationship between the abuser and the child, often the mother’s partner.

Unemployment, low socio-economic status, low education levels and substance abuse are also notable risk factors for child abuse.

Females inflict more violence in general but males inflict more life threatening violence. Men more commonly perpetrate sexual abuse.

Other risk factors include overcrowding, parental low self-esteem and impulsivity, caregiver history of being abused, curr= ent violence in the home, stress, health problems and job loss.

At the community level other risk facto= rs are poverty, high population turnover and overcrowding, social isolation of family unit from the community and lack of social support systems for the family. Societies with = high levels of inequality and no social protective policies for children are at higher ris= k of presenting abuse. Conflict and war also increase likelihood of abuse (1).

Among the physical consequences of abuse common ones are laceration= s, fractures, bruises, brain or nervous sy= stem injuries, burns and intra-abdominal injuries. Sexual and reproductive consequences include sexual dysfunction, sexually transmitted infections and unwanted pregnancy. Psychological factors include cognitive impairment, substance abuse, developmental delays, depression, anxiety, eating and sleeping disorders, hyperactivit= y, poor self-esteem, suicidal behaviour and post-traumatic stress disorder.

Some approaches wi= th promising results are included below.

Training in parent= ing: education on child development and skills in managing children. Training of health care professionals in identification and management of child abuse problems. Home visitation: providing information = and support for care of children as well as parental training. Services for victims of Child Abuse and Neglect (CAN): Screening of abuse by health-care professionals and training of health-care professionals= on how to detect and refer potential cases of abuse. Other therapeutic approaches include day care treatments, stimulation of communicatio= n to reduce isolation and other treatments for conditions related to sexual abuse. Oth= er services are directed to children who witness abuse or to adults who where ab= used as children. Legal measur= es include the development or strengthening of child protection services, the creation of child fatality review teams, strengthening of arrest and prosecution policies, and mandatory treatment of offenders. Efforts within the community include school programmes that teach children how to identify threatening situations. Advocacy interventions are intended to increase community awareness= and educate the public a= bout the problem. At a societal level the strengthening of prevention policies can foster the development of = community, health and legal interventions.

Public health efforts should therefore be concentrated in the follo= wing areas (1). Improving the monitoring and assessment techniques for child abuse; developing or strengthening response systems which need to integrat= e health, educational and legal component= s; setting up mandatory reporting; prosecuting abusers; improving capacity of health professionals to detect and refer potential cases; and coordinate these referrals with appropriate actions by the justice system. Improving the scope and nature of the d= ata obtained to describe the problem, increasing research efforts aimed at evaluating interventi= ons or developing n= ew ones, addressing the issues of neglect and risk factors.
Training professio= nals to look for and deal with potential cases of abuse.

Another vulnerable population is the elderly.

Abuse and neglect = of the elderly has been defined as (1, 2):
A single, or repea= ted act, or lack of appropriate action, occurring within any relationship where there is an expectat= ion of trust which causes harm or distress to an older person”.
However, there is = no universally agreed or standardized definition as yet.
An alternative definition is (3): “abuse is a violation of an individual's human and civil rights by any other person or persons”.

Abuse of the elder= ly includes:
physical abuse = 211; the use of physical force that may result in bodily injury, physical pain, or impairment; psychological abuse – the inflict= ion of anguish, pain, or distress through verbal or nonverbal acts; sexual abuse – non-consensual sex= ual contact of any kind with an elderly person, or sexual contact with any person incapable of giving conse= nt;
neglect – the refusal or failure to fulfil any part of a person's obligations or
duties to an elder= ly person, this may include intentional neglect or unintentional neglect due to ignorance = or inexperience; financial or material abuse – the illegal or improper use of = an elderly person's fun= ds, property or assets;
discriminatory abu= se – ageism, racism.

Abuse of the elder= ly can exist in domestic or institutional settings.
There is a concern that the magnitude of the problem of elder abuse may be increasing = as this sector of the global population= is undergoing a marked increase. By the year 2025, the population older than 60 years will be 1.2 billion or double that of 1995 and about 80% of these will be in the developing world. The structure of families is also changing and increased mobilizati= on is deteriorating family suppo= rt systems. Additionally only 30% of the world’s elderly are covered by= some type of pension scheme thus highlighting the lack of government social support for this population. Given the lack of official sources, information on the extent of the problem has largely relied on surveys. A large number of th= ese report a prevalence of about 4–6%. Abuse is usually physical but also appe= ars in the form of sexual and financial abuse. Psychological forms of abuse may also be relatively high and can be more difficult to identify. Most surveys report no significant differences by age and sex. Many surveys indicate that women are more likely to = be abused than men, and their experience is likely to be of the more serious forms = of abuse. Survey resul= ts suggest that physical and psychological abuse is higher in institutional <= /span>settings than in home settings. The difficulty of identifying cases of neglect makes it likely that the problem of elder abuse is currently underestimated. = ;However, there is a limited research ba= se, especially in terms of incidence and prevalence. Little research has emerged from lower income countries; the research base is almo= st exclusively from higher income countries.

Elder abuse, like other types of domestic violence, is extremely complex. Generally a combination of psychological, social, and economic factors, along w= ith the mental and physical conditions of the victim and the perpetrator, contribute to the occurrence= of elder maltreatment (4).
Some possible risk factors for elder abuse are:

relationship with abuser – spouse, dependant adult children

physical and cogni= tive impairments

strained family relationships

caregiver stress.&= #13;
At the community level, social isolation is an important factor for mistreatment and may be= either a cause or a consequence of abus= e. At the socie= tal level, depiction of the elderly as frail, weak or dependent can facilitate= situations of abuse or exploitation. &#= 13;Other elements include the erosion of intergenerational bonds, systems of inheritance where women or men are discriminated against, migration of younger population that erodes family ties and loss of a role in society for = the elderly.
Who are the abusers?
It has been estima= ted that roughly two thirds of all elder abuse perpetrators are family = members, most often the victim’s adult child or spouse. Abusers in many instances are financially dependent on the elder̵= 7;s resources and have problems related to alcohol and drugs. In countries where three or more generations live together it may be necessary to consider the intergenerational nature of violenc= e.

Based on surveys conducted on populations, higher proportions of th= e elderly that are abused suffer from depression and anxiety when compared to non-abused populations. Other feelings include shame, guilt, alienation and helplessness. Some longitudinal studies have shown that stress due to abuse can be a serious contributing fac= tor for premature death. Other consequences include physical injury (which can be more severe than in other age groups), gastrointestinal disorders, chronic pain syndromes, sexually transmitted diseases, depressi= on and suicidal thoughts or behaviour. In institutional settings abuse can occur because of inadequate car= e, problems with staffing, poor environmen= tal conditions and inadequate institutional policies. Much institutional abuse occurs in settings with unquestioned regimentation and exploitation of dependence. There is a long history of advanced welfare systems bei= ng unable to prevent institutional abuse. In instituti= onal settings abuse can involve deficiencies in food preparation, poor assessment of health care needs, injuries, pressure sores, quality of care, physical restraints, housekeeping deficiencies and lack of dignity. These types = of problems have been reported in institutions regardless of the type of advertised quality of care.

There are many indicators of elder abuse relating to either the elderly or the caregiver.

The elderly may show consequences of abuse at the physical, behavioural or emotional, sexual or financial levels (1).

Phys= ical indicators include:

comp= laints of being physically assaulted

unex= plained falls and injuries

burns and bruises in unusual places or of an unusual type

cuts, finger marks or other evidence of physical restraint

exce= ssive repeat prescriptions or under-usage of medication

maln= ourishment or dehydration without an illness-related cause

evid= ence of inadequate care or poor standards of hygiene

pers= on seeks medical attention from a variety of doctors or medical centres. =

Beha= vioural and emotional indicators include:

chan= ge in eating pattern or sleep problems

fear, confusion or air of resignation

pass= ivity, withdrawal or increasing depression

help= lessness, hopelessness or anxiety

cont= radictory statements or other ambivalence not resulting from mental confusion

relu= ctance to talk openly

avoi= dance of physical, eye or verbal contact with caregiver

older person is isolated by others.

Sexu= al indicators include:

comp= laints of being sexually assaulted

sexu= al behaviour that is out of keeping with the older person's usual relationshi= ps and previous personality

unex= plained changes in behaviour, such as aggression, withdrawal or self-mutilation= 3;

unus= ual sexual behaviour

freq= uent complaints of abdominal pain, or unexplained vaginal or anal bleeding =

recu= rrent genital infections, or bruises around the breasts or genital area

torn, stained or bloody underclothes.

Fina= ncial indicators include:

with= drawals of money that are erratic, or not typical of the older person <= /div>
with= drawals of money that are inconsistent with the older person's means
chan= ging a will or property title to leave house or assets to "new friends or relatives"

prop= erty is missing

older person "can't find" jewellery or personal belongings =

susp= icious activity on credit card account

lack= of amenities, when the older person could afford them

untr= eated medical or mental health problems

leve= l of care not commensurate with the older person’s income or assets. =

Indi= cators in the caregiver may include:

care= giver appears tired or stressed

care= giver seems excessively concerned or unconcerned

care= giver blames the older person for acts such as incontinence

care= giver behaves aggressively

care= giver treats the older person like a child or in a dehumanized way
care= giver has a history of substance abuse or abusing others

care= giver does not want the older person to be interviewed alone

care= giver responds defensively when questioned – may be hostile or evasive = ;

care= giver has been providing care to the older person for a long period of time. = ;

Efforts to control or prevent elder abuse have been mainly applied = in high-income countries. Between countries, there are differences in the level of implementation of programs or acknowledgement of the problem. Most responses to this type of abuse incorporate activities between social services, he= alth care and legal systems. Additionally, many programmes have been developed within contexts of prevention of violence within the family. From the perspective of social services the availability of medical, legal and financial support networks is the key for establishing prevention <= span lang=3DEN-GB style=3D'font-family:Arial;mso-ascii-font-family:Arial;mso-bi= di-font-family: Arial;mso-hansi-font-family:Arial'>activities. Other services include the creation of emergency shelters and the use of telephone help-lines to report or refer cases of abuse. There is also a need to screen caregivers, assign motivation and suitability to provide effective and humane care. Educating caregivers to identify their <= span lang=3DEN-GB style=3D'font-family:Arial;mso-ascii-font-family:Arial;mso-bi= di-font-family: Arial;mso-hansi-font-family:Arial'>own early warning signs of anger or dissatisfaction with caregiving may also help to avoid an abusive situation. = 3;In some lower-income countries, with le= ss social support, self-help groups have been established to confront the problem. In some countries in Latin America, Eur= ope and Australia, the health care sector has played an important role. In other countries participation of medical professionals has been less. There is a need for the prompt identification of abuse cases through early signs of abuse and the provision of adequate referral services.

Other important elements for prevention involve the development and= passing of laws aimed at protecting the elderly. Even when these laws exist there is a need to foster appropriate responses that include ethica= l, cultural and professi= onal factors. Informing the community about the types of abuse and the signs of abuse is an important element supporting prevent= ion. Other techni= ques that have been used include the use of media campaigns and a more direct approach of increasing awareness among the elderly providing information on services and referral systems. = Zero tolerance campaigns have been help= ful in addressing domestic violence in the United Kingdom and the United States. Such an appro= ach may also be applicable to the elder abu= se problem.

Currently, there are gaps in our knowledge of causes and risk facto= rs for abuse and additional research is needed. Similarly, there is a need to know <= span lang=3DEN-GB style=3D'font-family:Arial;mso-ascii-font-family:Arial;mso-bi= di-font-family: Arial;mso-hansi-font-family:Arial'>more about the impact of abuse on diffe= rent populations and to conduct rigorous evaluation of preventive measures to determine which are t= he most effective. &= #13;There is also the need, by legal means,= to strengthen the basic rights of people and address and change abusive traditions. The topic of elder abuse is just beginn= ing to be discussed or even recognized in some settings and many lessons learned from other are= as of violence prevention can benefit the promotion of more integrated actions for elder abuse.
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UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if (MHTMLPrefix !=3D "") href =3D RemoveFilePrefixFromHref(href) if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; =09 if (MHTMLPrefix !=3D "") PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(obj.mSldHref= )) else PPTSld.location.replace(obj.mSldHref) =09 if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 if (MHTMLPrefix !=3D "") PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(href)) else PPTSld.location.replace(href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('

' + ENDSHOW_MESG + '
') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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	Gen= eral lesson description
	This s= ection explores the abuse and neglect of children and the elderly. It explains t= he global burden of these types of violence as well as the determinants and = risk factors related to violence against these groups of individuals. Potential strategies for obtaining information and controlling or preventing these types of violence are taught by means of examples from the literature. Ba= sic information on legal and forensic implications for these types of violenc= e is provided. It addresses important recommendations for reducing both the ab= use and neglect of children and the elderly.


	This l= esson addresses some important factors and characteristics associated with the perpetration of violence against two vulnerable populations, children and= the elderly.


	In 199= 9, the WHO Consultation on Child Abuse Prevention drafted the following definition:<= /font>
	Child = abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial= or other exploitation resulting in actual or potential harm to the childR= 17;s health, survival, development or dignity in the context of a relationship= of responsibility, trust, or power.
	This d= efinition in a broad sense covers acts by parents or caregivers that result in harm to t= he child. This harm can be physical, psychological, sexual or a consequence = of neglect or deprivation (1), and would include inadequate health care and medical neglect.


	Physic= al abuse refers to physical or bodily harm, or the potential for that, caused to children by their caregivers.
	Sexual= abuse is defined as acts where the child is used to sexually gratify the caregiver= .
	Emotio= nal abuse refers to the failure of a caregiver to provide a supportive environment = and includes acts such as restrictions of mobility, denigration, ridicule, threats and intimidation, discrimination and other forms of non-physical rejection.
	Neglec= t or negligent treatment refer to the failure of caregivers to provide a supportive environment for the child, although parents are in a position to do so, a= nd includes areas of health, education, emotional development, nutrition, shelter and safe living conditions.


	Global= estimates suggest that infants and very young children are at greater risk of fatal abuse than children aged 5-14 years. In most places however there are high levels of misclassification as deaths that are infanticide are classified= as due to other causes (1).
	Data o= n non-fatal abuse comes from several sources. Official statistics are not very useful because legal and cultural variability in the definitions of child abuse = make data difficult to compare. Population-based surveys are probably a more accurate source of information.
	Physic= al abuse varies substantially as shown in the table above. Physical punishment is = not limited to the home in many cases and extends to the school and other institutions.
	Sexual= abuse estimates also depend on the definitions used and who is included. Estima= tes vary substantially in surveys depending on whether caregivers, peers or no physical contact are included in the definition.
	Emotio= nal and psychological abuse has been even less studied although shouting and thre= ats appear to be the most common forms used.
	Defini= tions of neglect vary also by country but appear to be more common than other form= s of abuse.


	The mo= st common individual factors that increase a child’s vulnerability for abuse = are:
	age
	as men= tioned before younger children and infants tend to be at higher risk of physical abuse;=
	sexual= abuse rates tend to be higher in puberty;
	sex
	female= s are usually more frequently victimized than males (up to three times more);
	while = most forms of abuse and neglect are directed towards females, harsh physical punishment seems to be more frequent against males.
	Also p= remature infants, twins and handicapped children are at higher risk of being abuse= d. However these latter characteristics are less important than parental or societal factors.
	One of= the most important risk factors is a non-biological relationship between the abuser and the child, often the mother’s partner.
	Unempl= oyment, low socio-economic status, low education levels and substance abuse are also notable risk factors for child abuse.
	Female= s inflict more violence in general but males inflict more life threatening violence. Men more commonly perpetrate sexual abuse.
	Other = risk factors include overcrowding, parental low self-esteem and impulsivity, caregiver history of being abused, current violence in the home, stress, health problems and job loss.
	At the= community level other risk factors are poverty, high population turnover and overcrowding, social isolation of family unit from the community and lack= of social support systems for the family. Societies with high levels of inequality and no social protective policies for children are at higher r= isk of presenting abuse. Conflict and war also increase likelihood of abuse (= 1).


	Some a= pproaches with promising results are included below.

	Traini= ng in parenting: education on child development and skills in managing children= .
	Traini= ng of health care professionals in identification and management of child abuse proble= ms.
	Home v= isitation: providing information and support for care of children as well as parental training.
	Servic= es for victims of Child Abuse and Neglect (CAN): Screening of abuse by health-care professionals and training of health-care professionals on how to detect = and refer potential cases of abuse. Other therapeutic approaches include day = care treatments, stimulation of communication to reduce isolation and other treatments for conditions related to sexual abuse. Other services are directed to children who witness abuse or to adults who where abused as children.
	Legal = measures include the development or strengthening of child protection services, the creation of child fatality review teams, strengthening of arrest and prosecution policies, and mandatory treatment of offenders.
	Effort= s within the community include school programmes that teach children how to identify threatening situations.
	Advoca= cy interventions are intended to increase community awareness and educate the public about the problem.
	At a societal level the strengthening of prevention policies can foster the development of community, health and legal interventions.


	Public= health efforts should therefore be concentrated in the following areas (1).
	Improv= ing the monitoring and assessment techniques for child abuse; developing or strengthening response systems which need to integrate health, educational and legal components; setting up mandatory reporting; prosecuting abusers; improving capacity of health professionals to detect and refer potential cases; and coordinate these referrals with appropriate actions by the jus= tice system.
	Improv= ing the scope and nature of the data obtained to describe the problem, increasing resea= rch efforts aimed at evaluating interventions or developing new ones, address= ing the issues of neglect and risk factors.
	Traini= ng professionals to look for and deal with potential cases of abuse.<= br>


	Anothe= r vulnerable population is the elderly.
	Abuse = and neglect of the elderly has been defined as (1, 2):
	A sing= le, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person”.
	Howeve= r, there is no universally agreed or standardized definition as yet.
	An alt= ernative definition is (3): “abuse is a violation of an individual's human a= nd civil rights by any other person or persons”.


	Abuse = of the elderly includes:
	physic= al abuse – the use of physical force that may result in bodily injury, physi= cal pain, or impairment;
	psycho= logical abuse – the infliction of anguish, pain, or distress through verbal or nonverbal acts;
	sexual= abuse – non-consensual sexual contact of any kind with an elderly person, or sexu= al contact with any person incapable of giving consent;
	neglec= t – the refusal or failure to fulfil any part of a person's obligations or=
	duties= to an elderly person, this may include intentional neglect or unintentional neglect due= to ignorance or inexperience;
	financ= ial or material abuse – the illegal or improper use of an elderly person's funds, property or assets;
	discri= minatory abuse – ageism, racism.


	Abuse = of the elderly can exist in domestic or institutional settings.
	There = is a concern that the magnitude of the problem of elder abuse may be increasing as this sector of the global population is undergoing a marked increase. By the y= ear 2025, the population older than 60 years will be 1.2 billion or double th= at of 1995 and about 80% of these will be in the developing world.
	The st= ructure of families is also changing and increased mobilization is deteriorating fam= ily support systems. Additionally only 30% of the world’s elderly are covered by some type of pension scheme thus highlighting the lack of government social support for this population.
	Given = the lack of official sources, information on the extent of the problem has largely re= lied on surveys. A large number of these report a prevalence of about 4–= 6%.
	Abuse = is usually physical but also appears in the form of sexual and financial abuse. Psychological forms of abuse may also be relatively high and can be more difficult to identify. Most surveys report no significant differences by = age and sex. Many surveys indicate that women are more likely to be abused th= an men, and their experience is likely to be of the more serious forms of ab= use.
	Survey= results suggest that physical and psychological abuse is higher in institutional settings than in home settings.
	The di= fficulty of identifying cases of neglect makes it likely that the problem of elder ab= use is currently underestimated.
	Howeve= r, there is a limited research base, especially in terms of incidence and prevalence. Little research has emerged from lower income countries; the research bas= e is almost exclusively from higher income countries.


	Elder = abuse, like other types of domestic violence, is extremely complex. Generally a combination of psychological, social, and economic factors, along with the mental and physical conditions of the victim and the perpetrator, contrib= ute to the occurrence of elder maltreatment (4).
	Some p= ossible risk factors for elder abuse are:
	relati= onship with abuser – spouse, dependant adult children
	physic= al and cognitive impairments
	strain= ed family relationships
	caregi= ver stress.
	At the= community level, social isolation is an important factor for mistreatment and may be either a cause or a consequence of abuse.
	At the= societal level, depiction of the elderly as frail, weak or dependent can facilitate situations of abuse or exploitation.
	Other = elements include the erosion of intergenerational bonds, systems of inheritance wh= ere women or men are discriminated against, migration of younger population t= hat erodes family ties and loss of a role in society for the elderly.<= br>
	Who ar= e the abusers?
	It has= been estimated that roughly two thirds of all elder abuse perpetrators are fam= ily members, most often the victim’s adult child or spouse. Abusers in = many instances are financially dependent on the elder’s resources and ha= ve problems related to alcohol and drugs.
	In cou= ntries where three or more generations live together it may be necessary to consider t= he intergenerational nature of violence.


	There = are many indicators of elder abuse relating to either the elderly or the caregiver= .
	The el= derly may show consequences of abuse at the physical, behavioural or emotional, sexual or financial levels (1).
	Physic= al indicators include:
	compla= ints of being physically assaulted
	unexpl= ained falls and injuries
	burns = and bruises in unusual places or of an unusual type
	cuts, = finger marks or other evidence of physical restraint
	excess= ive repeat prescriptions or under-usage of medication
	malnou= rishment or dehydration without an illness-related cause
	eviden= ce of inadequate care or poor standards of hygiene
	person= seeks medical attention from a variety of doctors or medical centres.
	Behavi= oural and emotional indicators include:
	change= in eating pattern or sleep problems
	fear, = confusion or air of resignation
	passiv= ity, withdrawal or increasing depression
	helple= ssness, hopelessness or anxiety
	contra= dictory statements or other ambivalence not resulting from mental confusion
	reluct= ance to talk openly
	avoida= nce of physical, eye or verbal contact with caregiver
	older = person is isolated by others.
	Sexual= indicators include:
	compla= ints of being sexually assaulted
	sexual= behaviour that is out of keeping with the older person's usual relationships and previous personality
	unexpl= ained changes in behaviour, such as aggression, withdrawal or self-mutilation
	unusua= l sexual behaviour
	freque= nt complaints of abdominal pain, or unexplained vaginal or anal bleeding
	recurr= ent genital infections, or bruises around the breasts or genital area
	torn, = stained or bloody underclothes.
	Financ= ial indicators include:
	withdr= awals of money that are erratic, or not typical of the older person
	withdr= awals of money that are inconsistent with the older person's means
	changi= ng a will or property title to leave house or assets to "new friends or relatives"
	proper= ty is missing
	older = person "can't find" jewellery or personal belongings
	suspic= ious activity on credit card account
	lack o= f amenities, when the older person could afford them
	untrea= ted medical or mental health problems
	level = of care not commensurate with the older person’s income or assets.
	Indica= tors in the caregiver may include:
	caregi= ver appears tired or stressed
	caregi= ver seems excessively concerned or unconcerned
	caregi= ver blames the older person for acts such as incontinence
	caregi= ver behaves aggressively
	caregi= ver treats the older person like a child or in a dehumanized way
	caregi= ver has a history of substance abuse or abusing others
	caregi= ver does not want the older person to be interviewed alone
	caregi= ver responds defensively when questioned – may be hostile or evasive
	caregi= ver has been providing care to the older person for a long period of time.


	Effort= s to control or prevent elder abuse have been mainly applied in high-income countries. Between countries, there are differences in the level of implementation of programs or acknowledgement of the problem.
	Most r= esponses to this type of abuse incorporate activities between social services, health care and legal systems. Additionally, many programmes have been developed within contexts of prevention of violence within the family. From the perspective of social services the availability of medical, legal and financial support networks is the key for establishing prevention activit= ies. Other services include the creation of emergency shelters and the use of telephone help-lines to report or refer cases of abuse.
	There = is also a need to screen caregivers, assign motivation and suitability to provide effect= ive and humane care. Educating caregivers to identify their own early warning signs of anger or dissatisfaction with caregiving may also help to avoid = an abusive situation.
	In som= e lower-income countries, with less social support, self-help groups have been establish= ed to confront the problem. In some countries in Latin America, Europe and Australia, the health care sector has played an important role. In other countries participation of medical professionals has been less.
	There = is a need for the prompt identification of abuse cases through early signs of abuse and= the provision of adequate referral services.


	Other = important elements for prevention involve the development and passing of laws aimed= at protecting the elderly. Even when these laws exist there is a need to fos= ter appropriate responses that include ethical, cultural and professional factors.
	Inform= ing the community about the types of abuse and the signs of abuse is an important element supporting prevention.
	Other = techniques that have been used include the use of media campaigns and a more direct approach of increasing awareness among the elderly providing information = on services and referral systems.
	Zero t= olerance campaigns have been helpful in addressing domestic violence in the United Kingdom and the United States. Such an approach may also be applicable to= the elder abuse problem.


	Curren= tly, there are gaps in our knowledge of causes and risk factors for abuse and additional research is needed. Similarly, there is a need to know more about the imp= act of abuse on different populations and to conduct rigorous evaluation of preventive measures to determine which are the most effective.
	There = is also the need, by legal means, to strengthen the basic rights of people and address and change abusive traditions.
	The to= pic of elder abuse is just beginning to be discussed or even recognized in some settin= gs and many lessons learned from other areas of violence prevention can bene= fit the promotion of more integrated actions for elder abuse.