Detecting abuse in patients with disability: Recognising the signs

Amanda Lyons

30/07/2018 3:36:38 PM

People with disability who receive institutional care are vulnerable to abuse – from carers, family members and other residents – but GPs can be a strong ally for this patient population.

People with disability are vulnerable to and have higher rates of physical and sexual abuse.
People with disability are vulnerable to and have higher rates of physical and sexual abuse.

Josie* was raped by another resident in the grounds of her village-style group home complex for people with disability; when she reported the incident to an on-site worker, she was told to ‘just keep out of [her rapist’s] way’.
A severely disabled girl had her nose nearly bitten off during a night-time attack by a fellow resident in her group home.
Neither of these assaults were reported to the police. But two parents who did report their daughter’s sexual assault by a disability worker in respite accommodation found out afterwards that two sets of other parents had had the same experience.
All of these incidents were reported to the Victorian Parliament’s Inquiry into abuse in disability services in 2016, part of an avalanche of similar horror stories that saw the Family and Community Development Committee leading the inquiry to declare that abuse in Victorian disability services was ‘widespread’.
‘People with disability are particularly vulnerable to being abused, and they have higher rates than the normal population of both physical and sexual abuse,’ Professor Jan Coles, Professor of General Practice at Monash University and leading family violence educator, told newsGP.
‘And it’s often hard for them to talk about it, because their disability may affect communication, so it’s very difficult for them to tell their doctors what’s happening in their lives.’
One of the reasons people with disability can have a heightened vulnerability to abuse is that they may require some form of institutional care, such as a supported residential service (SRS). This means they are reliant on staff and carers while also being exposed to a wider range of people than they would be at home.
To counter this vulnerability, institutions are required to have checks and balances in place.
‘There is an expectation that the institution’s support workers have training in this area [of abuse], and that there are processes in place where complaints can be passed up the line and appropriate actions be taken,’ Associate Professor Robert Davis, GP and Chair of the RACGP Disability Specific Interests network, told newsGP.
However, there is some concern that financial imperatives may sometimes override such checks and balances, as Professor Coles has found in her research on elder abuse in residential aged care.
‘The advocates I’ve spoken to have been very concerned about the number of staff cuts there have been [in the sector] and in the more skilled areas,’ Professor Coles said. ‘So facilities are employing staff who are less skilled and perhaps less able to respond to people who are difficult or have complex needs.’
Associate Professor Davis has found that such issues with staffing – for example, a lack of training about how to respond to suspected abuse between residents, or how to handle patients with complex needs – can have a strong impact on the wellbeing of people with disability who are receiving institutionalised care.
‘Certainly in a supported residential service, if you have even a few staff that don’t have [the right] skills it can impact on the quality of life of the person,’ he said.
Professor Coles believes that GPs, as health professionals who visit institutions but are not employed by them, are perfectly placed to help identify and flag potential abuse.
‘The GP is not an insider, but a continual visitor, so they’re in a really good position to raise awareness and to also make sure that people in residential facilities are getting good care. They can raise any issues with management,’ she said.
Associate Professor Davis agrees, pointing out that a GP’s only loyalty is to their patients.
‘You may have a number of clients in [an SRS], and sometimes one of the clients might be the perpetrator and another might be a victim,’ he said. ‘There are times where GPs identify that as an issue and can report it.
‘The [SRS staff] might have mixed loyalties, they are caring for clients, abuser and abusee, and sometimes you need to advocate on behalf of that person that’s being abused.’
Helping to identify and assist in cases of suspected abuse of people with disability can come with particular challenges of its own, but there are ways GPs can work within these constraints.
‘GPs will be seeing this group of patients regularly and as part of the annual health check one of the requirements is that you pay attention to the vulnerability of the patient with disabilities to abuse,’ Associate Professor Davis said.
‘It’s one of those things that if you think about it, you’re likely to pick up where there might be issues; although because [the person with disability] is often very reliant on the carer that presents with them, so it can be pretty hard to know what’s going on.’
Professor Coles recommends some things GPs should keep in mind, as well as signs of which they can be aware.
‘[GPs are] trained to think hidden infection: let’s do a urine test, let’s listen to their lungs,’ she said. ‘But we’re not trained to think, hey, this could be violence occurring in an aged care facility or a group home.
‘But keep in mind that [abuse] is far more prevalent than we think it is.
‘Often, people won’t communicate, so what you’ll see is behaviour change; patients are acting out.
‘You often have to take opportunities such as when you are doing a physical examination with the person, just raising the possibility, “Is there anything else happening that could be making you feel bad?”’
The rollout of the National Disability Insurance Scheme (NDIS) means there are significant changes on the horizon of disability care, and the area of preventing and providing assistance for abuse is no exception.
‘Under the current system, there is a Disability Discrimination Commissioner, but the NDIS
Commission will take on that role in future,’ Associate Professor Davis said.
‘It’s changing from state-based services to national services, and it’s looking like the NDIS Commission will be fully rolled out in 2020.’
Associate Professor Davis believes the AHRC’s review of the oversight and administration processes in the care of people with disabilities is a positive move that helps pinpoint some of the key issues in institutional care. But he is also aware of the significant challenges facing the transition to an NDIS-implemented system – in part because the new system will move further away from institutional care.
‘It’s going to be a particular challenge, because the NDIS allows for more informal networks of parents and family,’ he said.
‘At least with larger organisations you have a process of quality control that goes through the organisation, but when there are individuals involved it can be challenging and [people with disabilities] can be a bit more vulnerable.’
It remains to be seen how the transition to the NDIS will affect oversight for abuse and violence towards people with disability. However, whether abuse is taking place within an institution or in the home, both Professor Coles and Associate Professor Davis agree that GPs are a key source of support in these cases.
‘First and foremost, as a patient advocate we need to be looking after them and protecting them, just like we would any other patient,’ Professor Coles said.
‘We’ve really got to come to terms with what we really want for our people for disability and what we will and what we won’t accept as a community.’
* Not her real name.

Abuse Disability National Disability Insurance Scheme NDIS

newsGP weekly poll Which of the below incentive amounts (paid annually) would be sufficient to encourage you to provide eight consultations and two care plans to a residential aged care patient per year?

newsGP weekly poll Which of the below incentive amounts (paid annually) would be sufficient to encourage you to provide eight consultations and two care plans to a residential aged care patient per year?



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