History: About Adult Protective Services from 1960 to 2000
The history of Adult Protective Services in the United States is difficult to trace. Some of it has been gleaned from oral history and materials generously provided by Marilyn Whalen from the Tennessee Department of Human Services.
The earliest study of Adult Protective Services was conducted by Virginia Lehmann for the National Council on the Aging in 1960. The report was used as the basis for a national conference held in 1963 (Hall & Mathiasen, 1963).
The 1961 White House Conference on Aging recommended, “That social agencies, legal aid and bar associations and the medical profession increase their cooperation and continue their study of ways to facilitate the provision of protective services to older people.” (Douglas & Burford, 1974)
A number of demonstration projects were funded by the Administration on Aging in the 1960’s to “determine the effect of certain service delivery systems on the group of elderly identified as in need of protective services.” (Dunkle, 1984) But by 1968 there were less than twenty community protective service programs in the country (Mixson, 1995).
The real impetus for states to provide Adult Protective Services came with the passage of Title XX of the Social Security Act in 1974. Broad language in the Act gave permission for states to use Social Services Block Grant (SSBG) funds for the protection of adults as well as children (Mixson, 1995).
By 1978, John Regan noted that almost twenty states had enacted legislation mandating state social service agencies to provide both casework and delivery of protective services to adults (Regan). At that time, Regan voiced his concern about the paternalistic nature of such services, and the possible harm to client autonomy in the exercise of parens patriae powers by the states (Regan, 1978).
Nonetheless, by 1981, “All the states, in one way or another, noted that they had an office with responsibility to provide protective services to some segment of the population… providing such services to the needy even in the absence of authorizing legislation.” At that time 83% of the states indicated that they were in favor of federal legislation to support mandatory reporting of adult abuse. (U.S. Congress, 1981)
In 1980 states reported that they had spent a total of $83,260,303 in SSBG funds for Adult Protective Services. However, “The problem of elder abuse exists in epidemic proportions. The incidence of such abuse appears to be growing and few states have allocated the kind of resources they need to meet the problem.” (U.S. Congress, 1981)
Despite the introduction of the federal Prevention, Identification and Treatment of Adult Abuse Bill of 1980, sponsored by Mary Rose Okar to provide funding incentives to the states for the provision of Adult Protective Services, and recommendations from a series of Senate reports, no federal action was taken. (U.S. Congress, 1981).
Absent federal direction on this issue, many states continued to adopt their own statutes providing Adult Protective Services which were usually delivered by state or local social service agencies (Regan, 1978).
In 1985 Senator Claude Pepper recommended that “Congress should act immediately to assist the states in preventing, identifying and assisting our nation’s elder abuse victims.” (U.S. Congress). By this time 46 states had an office responsible for the delivery of Adult Protective Services. Although 36 states indicated that they thought elder abuse was increasing, the total amount of SSBG funds being used for Adult Protective Services programs had dropped to a total of $48,119,698, a reduction of 42% since 1980 (U.S. Congress, 1985). SSBG spending was further reduced to $39,329,324 by 1993 (APWA Report, 1994).
During the 1980’s, the focus on elder abuse, rather than Adult Protective Services, increased. Researchers perceived elder abuse as a more easily identified subject for study, and a more dramatic issue to present to legislators and the public. One of the results of this shift of focus was the increasing invisibility of Adult Protective Services. States continued to provide the service, but as state laws evolved, definitions became increasingly state specific, as did the programs.
While estimates of the prevalence of the problem continued to rise, accurate data collection of actual cases served by local Adult Protective Services programs continued to be difficult to achieve due to a lack of uniform definitions and reporting requirements (Whalen, 1999).
By 1991, 42 states had mandatory reporting laws, and 34 were providing protective services to impaired adults as well as the elderly. Mandatory reporting had become a highly charged issue which was seen by some as a threat to client autonomy (U.S. Congress, 1991). A study that year by the Government Accounting Office concluded that mandatory reporting did not necessarily prevent abuse. The study identified a number of other factors that were more effective in abuse prevention. However the study also pointed out that mandatory reporting was second only to public and professional awareness in effectiveness in case identification (U.S. Congress, 1991).
The study results did not deter additional states from adding mandatory reporting requirements to their Adult Protective Services laws. By the end of the 1990’s, only five states did not mandate reporting.
From 1986 to 1989 the number of states using SSBG funds to support their Adult Protective Services programs had decreased from 46 to 30. In addition, the funding level had dropped. As a result of increasing pressure for state mandated child welfare services, the average state was only allocating 4% of its SSBG funding for protective services for adults and the elderly (U.S. Congress, 1991).
States were spending an average of $45.03 per child and only $3.80 per adult on protective services (U.S. Congress, 1990). “Given this situation, it might benefit victims of elder abuse and neglect if Title XX of the Social Security Act required the states to use a percentage of SSBG funds for their Adult Protective Services programs.” (U.S.Congress,1991)
A continuing issue was the provision of protective services to self-neglect-in disabled and elderly adults (Research Conference Recommendations, 1986). While researchers insisted that self-neglect was not a form of abuse, Adult Protective Services practitioners stated that self-neglecting adults made up the majority of their caseloads. Because the cases were complex and time intensive, other community agencies either refused to get involved, or did so only briefly, then turned to Adult Protective Services for help.
Diminishing resources continued to plague state Adult Protective Services programs during the late 1980’s and 1990’s. In addition to inflation and cutbacks of SSBG funds, reduction in other federal funds used to provide supportive services such as Meals on Wheels and adult foster care made it increasingly difficult for Adult Protective Services workers to develop and implement effective service plans once the initial assessment phase was completed. “In the first analysis, Adult Protective Services can only be as effective as the resources available to permit intervention into elder abuse cases.” (Kosberg & Rouse, 1990)
Despite at least eight Congressional hearings and numerous studies and reports, little had changed in three decades. The 1995 White House Conference on Aging made a number of recommendations regarding preventing elder mistreatment which have yet to be implemented (Official White House Conference Report, 1995).
History: The Adult Protective Services Model
While each state created its laws and regulations independently, most followed a similar model of protective service delivery. Based on social casework and systems approaches, most programs “provide elder abuse victims with a coordinated, interdisciplinary system of social and health services. The services are designed to enable an elderly individual or other vulnerable adult to continue living independently at home and to protect him from abuse.” (U.S. Congress, 1991)
The majority, (90%), of states provide services to vulnerable adults age 18 and older who represent approximately 30% of the cases nation wide. Areas of abuse covered by state statutes include physical, sexual, and emotional abuse, financial exploitation and caregiver neglect as well as self-neglect. Definitions vary from state to state, but the core areas of mistreatment are consistent.
The primary activities covered by most state statutes include receiving reports; conducting investigations; evaluating client risk and capacity to agree to services; developing and implementing a case plan; counseling the client; arranging for a large variety of services and benefits and monitoring ongoing service delivery (APWA Report, 1994).
The problem of involuntary services has been, in large part, diffused by a NAPSA study conducted by Joy Duke. Results of the nationwide survey showed that less than 10% of adult protection client’s received services without their consent, and that all states made vigorous efforts to protect clients rights. “The focus is not on serving adults against their will, but rather on assuring that the critical services are not denied because the adult in need lacks capacity to consent to receive essential services.” (Duke, 1997)
The locus of states’ adult protection administrative structures varies. In two thirds of the states, the agency responsible for state administration resides with the Department of Social Services. The remaining one third are State Units on Aging with a sprinkling of Departments of Health and Rehabilitation. In the majority of states Adult Protective Services has a role in investigating abuse reports in long term care facilities. Sometimes this role is shared with the long-term care ombudsman and/or other regulatory agencies (APWA Report).
Regardless of location, there are certain basic principles which shape Adult Protective Services practice:
- The client’s right to self-determination
- The use of the least restrictive alternative
- The maintenance of the family unit whenever possible
- The use of community-based services rather than institutions
- The avoidance of blame
- That inadequate or inappropriate services are worse than none (U.S. Congress, 1981)
Because the profession has evolved from the ground up rather than as the result of research, practice tends to be pragmatic. Mixson advised that early in the relationship the practitioner “offer the individual one concrete piece of assistance, regardless of its relation to what the practitioner may view as the presenting problem.”
Mixson went on to discuss the importance of establishing trust with the client, “Regardless of the method in which the connection is made, the practitioner who attempts intervention without first having established this basis of trust and rapport is sabotaging the potential for success.” (Mixson, 91)