Aging & Mental Health 2001; 5(1): 56± 62

ORIGINAL ARTICLE

Risk factor characteristics in carers who physically abuse or neglect

their elderly dependants

A. M. CAMPBELL REAY1 & K. D. BROWNE 2

1
Department of Clinical Psychology,Walton Hospital, Chesterfield, & 2School of Psychology, University of Birmingham, UK

Abstract
This study investigates the prevalence of, and differences in, risk factor characteristics in a sample of two select
populations of carers, one of which physically abused their elderly dependants and one of which neglected them.
Nineteen carers (nine who had physically abused and 10 who had neglected their elderly relatives), who were referred to
clinical psychology by either their general practitioner or their psychiatrist, were invited to take part in this study. A
detailed history of risk factors was obtained, including history of alcohol dependency, type and history of mental ill
health, history of maltreatment earlier in life, who they were caring for, how long they had been a carer and whether they
felt isolated as a carer. Subjects were then given five assessments to determine whether there were any differences
between the two groups. These were the Conflict Tactic Scale, Strain Scale, Beck Depression Inventory, Beck Anxiety
Inventory and Cost of Care Index. An examination of the risk factors suggests that heavy alcohol consumption and past
childhood abuse by fathers were likely to lead to physical abuse. Significantly higher conflict and depression scores were
also present in the physical abuse group, while the neglect group had significantly higher anxiety scores. It is suggested
that these findings should be incorporated into an assessment of future risk of abuse or neglect by the carer.

Introduction TABLE 1. Who is likely to maltreat?

Those responsible for elderly dependent aged over 75

The prevalence of elder maltreatment in the
UK remains relatively unknown, with the exception of
Ogg & Bennett (1992), and difficult to determine.
However, there is sufficient research evidence to
suggest that the phenomenon is a significant social
problem, especially for those over the age of 75 years
(Pillemer & Finkelhor, 1988). Estimates of prevalence
vary but there is general agreement that at least 4% of
elderly people are maltreated by their carers (Pillemer
& Finkelhor, 1988). This would translate as 16 elderly
people who are subject to abuse or inadequate care
within a typical family doctor caseload of 400
elderly patients. Despite this, most cases of elder
maltreatment do not come to the attention of family
doctors without other agencies being involved (Ogg &
Bennett, 1992). Indeed, there is a lack of awareness of
risk factors among health professionals to help them
identify potential cases of elder abuse and neglect
(Kingston & Bennett, 1993). This reduces the chances
of any preventative work being carried out in this area.
years
The carer lives constantly with their elderly dependent.
An inexperienced or unwilling caregiver
A carer who has high expectations of their elderly
dependent
A caregiver who is suffering relationship conflict and
often exhibits hostile, threatening and/or aggressive
behaviour
A caregiver who has other caring demands, e.g. from
husband or children
A caregiver who is subject to high stress and strain, e.g.
unemployment, poor housing
A caregiver who is isolated and lacks community and
personal support
A carer who suffers poor physical health
A caregiver who has a history of mental health problems
A caregiver who has a history of clinical depression
A caregiver who has a history of anxiety disorder
A caregiver who has a history of alcohol abuse
A caregiver who has a history of drug abuse
A carer who was abused or neglected as a child, or
where there is a history of family violence

characteristics associated with the carers were identified

Risk factors as increasing the likelihood of elder abuse and neglect.
The 15 factors outlined in Table 1 have been identified
Risk factors were first developed from case histories from previous literature (Browne & Herbert, 1997;
which described elderly maltreatment. A number of Eastman, 1989; Ferguson & Beck, 1993).

Correspondence to: Dr Alice Reay, Department of Clinical Psychology, Walton Hospital, Whitecotes Lane, Chesterfield
S40 3HW, UK. Tel: +44 (0)1246 552871. Fax: +44 (0)1246 277106.
Received for publication 12th August 1999. Accepted 25th August 2000.

ISSN 1360± 7863 print/ISSN 1364± 6915 online/01/010056± 07 ½ Taylor & Francis Ltd
DOI: 10.1080/13607860020020654

It has been confirmed from research that the more
risk factors present in a family environment, the
greater the likelihood of elderly maltreatment
(Pillemer & Finkelhor, 1988). Assessment and
recognition of these predisposing conditions may
assist the professional in identifying potentially
abusive situations. Once recognized help can be
targeted at those most in need (Ballantyne, 1989),
possibly before serious mistreatment has occurred
(Feinmann, 1988). As it is not yet possible to
identify specifically conditions that lead to
maltreatment, it should be remembered that abuse
and neglect will not always occur given the presence
of risk factors (Pillemer & Suitor, 1988). Although
many risk factors have been identified, their relative
predictive power has not been systematically
researched or evaluated.
The development of screening instruments based on
risk factors is important, especially when one
considers the problems surrounding self-referral.
According to Kosberg (1988), the maltreated elder
characteristically tends to deny (consciously or
unconsciously) that the abuse or neglect has taken
place, or refuses to report it for a number of reasons
including:
fear of retaliation, of abandonment or of being
removed from the home or family setting;
the belief that the abuse was deserved;
the sense that there is nowhere else to go or that
nothing can be done to help;
shame in admitting such treatment from one’s own
family.
In the development of a screening instrument, high
sensitivity and specificity are required in order to
reduce the number of missed cases (false negatives)
and false alarms (false positives), respectively. To date,
few studies have considered whether those carers who
physically abuse their elderly dependants are different
in character from those who neglect them. This
distinction may be necessary to formulate a reliable
and valid screening tool.
Aims of the study
This study aims to investigate the prevalence of, and
differences in, risk factor characteristics in a sample of
two select populations of carers, one of which
physically abused their elderly dependants and one of
which neglected them. The hypothesis is that carers
who physically abuse their elderly dependants are
different in character from carers who neglect their
elderly dependants.
Method
The operational definitions used for this investigation
are as follows.
Risk factors for elder maltreatment 57
Physical abuse: act of commission, e.g. hitting,
slapping, burning, restraining and inappropriate use
of medication.
Neglect: act of omission, e.g. neglect of personal
hygiene, malnutrition and dehydration, etc.
Using these definitions of physical abuse and neglect,
19 subjects (nine who had physically abused and 10
who had neglected their elderly relatives), who were
referred to clinical psychology by either their general
practitioner or their psychiatrist, were invited to take
part in this study. The abuse or neglect was already
admitted to by the perpetrator and their victim.
In 12 cases (63%) the perpetrator of abuse (n=7) or
neglect (n=5) was the elderly spouse of the victim. For
six cases (32%) the offender was the victim’s adult
child (two abused and four neglected) and in one case
(5%) an elderly sister was the perpetrator of neglect.
These were then assigned into two groups; group 1,
containing six males and three females (age range 65±
72 years) who had admitted to physical abuse; and
group 2, containing three males and seven females
(age range 67± 74 years) who had admitted to neglect.
All had agreed to take part in this study. Five other
potential subjects were invited to take part but
declined.
All 19 cases lived constantly with their caregiver
and were not suffering from any form of dementia.
According to general practioner files, all carers were
retired and in good physical health and their housing
was deemed adequate for their needs. There was no
significant difference between those who physically
abused their elderly dependant and those who
neglected them for age and gender of the carer, or age
and gender of the victim. Although some subjects had
been prescribed medication in the past, no subjects
were currently on any psychotropic medication.
Procedures
After an explanation of what the study involved and
their agreement having been obtained, a detailed
history of risk factors was taken, including history of
alcohol dependency, type and history of mental ill
health, history of maltreatment earlier in life, who
they were caring for, how long they had been a carer
and whether they felt isolated as a carer.
Subjects were then given one history questionnaire
and five assessments to determine whether there were
any differences between the two groups. The assessments
were the Conflict Tactic Scale (CTS), Strain Scale (SS),
Beck Depression Inventory (BDI), Beck Anxiety
Inventory (BAI) and Cost of Care Index (CCI).
Materials
Background. History questionnaire (adapted from
Browne & Hamilton, 1998) designed to gather
58 A. M. Campbell Reay & K. D. Browne
information regarding age, sex, marital and domestic
status, alcohol and drug dependency, history of
physical and mental health problems, history of
maltreatment earlier in life, sense of isolation and
quality of the caring relationship.
CTS (Straus, 1979). This is a 20-item scale which
assesses the behaviours an individual might employ
during a conflict situation. Subjects are asked to rate
their responses to different conflict outcomes on a
scale ranging from never (score 0), to always (score
4). The scale is subdivided into six indices; reasoning,
hostile, expressive, threat, aggressive and abuse. For
the purpose of treatment evaluation a total score
(maximum = 68) was calculated for hostile, threat
and violent acts (excluding reasoning and expressive).
The higher the score, the more frequent and intense
the violence.
Machin’s (1980) SS. This is a measurement of carer
stress, encompassing domestic upset, personal distress
and negativity towards their dependant.There are 13
items with a maximum score of 39.
BDI (Beck & Steer, 1993a). Designed to assess the
severity of depression.The BDI is scored by summing
the ratings for each of the 21 items. Each item
consists of a group of four statements rated from 0 to
3. The maximum total score is 63. Scores: 10± 16
indicates mild depression, 17± 29 indicates moderate
depression and 30± 63 indicates severe depression.
BAI (Beck & Steer, 1993b). Designed to assess the
severity of anxiety. The BAI is scored by summing the
ratings for each of the 21 items. Each item is rated
from 0 to 3. The maximum total score is 63. Scores
of 20 and above would indicate an anxiety disorder.
CCI (Kosberg & Cairl, 1986). Designed as a case
management tool to assist in family assessments and
to identify actual or perceived problem areas in the
care of elderly relatives. The 20-item questionnaire
measures five dimensions: items 1± 4 measure
personal and social restrictions; items 5± 8 measure
physical and emotional health; items 9± 12 measure
value of caring; items 13± 16 measure care recipient as
provocateur; and items 17± 20 measure economic
costs. Each item is rated from 1 to 4 . A low score of
20 indicates a low `cost’ to the carer, while a high
score indicates a high `cost’ , with subscores for each of
the five dimensions indicating potential problem areas.
Reliability and validity
Three of the assessments, CTS, BDI and BAI, have a
long history, and various studies have shown good
test± retest reliability and validity (see assessment
manuals referenced above). As they are all widely used
in the clinical psychology field it was felt appropriate
to use them in this research project. Although the SS
is used widely in clinical psychology departments its
test± retest and validity are not documented. It is not
clear from the literature how reliable and valid the
CCI is.
Treatment of results
In order to determine whether there were any
differences between the physical abuse and neglect
groups on referral, their scores on the CTS, SS, BDI,
BAI and CCI were analysed using the Mann± Whitney
U test. Other risk factors were then examined
individually between groups using chi-squares or
Fisher’s exact test to determine whether there were
different risk factor characteristics present for each
group.
Results
The 15 risk factors identified from the literature were
examined in the abuse and neglect groups.
Psychometric assessments were used for six of these
factors. The results of this investigation are presented
in Table 2. Due to the nature of the referrals, the age
of the elderly dependant was over 75 years in all cases
(both abuse and neglect groups). The carers lived with
their dependant in all cases also. There were no high
expectations of the dependant by the carers in relation
to their ability to care for themselves. None of the
carers suffered from poor physical health and none
had a history of drug abuse.
Of the remaining 10 risk factors that could be
compared between the two groups, five factors showed
significant differences between the abuse and neglect
groups. These involved alcohol consumption,
childhood abuse by the father, current conflict tactics,
depression and anxiety (see Table 2).
With regard to alcohol abuse, seven out of nine
subjects (77%) who physically abused their relatives
consumed over 21 units of alcohol per week,
compared with only one subject in the neglect group
(10%). It could be argued that the high alcohol
consumption in the physical abuse group served to
reduce inhibitions and make physical abuse more
likely (see Table 3).
With regard to the past abuse of the subjects by
their biological fathers in childhood, six (66%) of the
physical abuse group reported this compared with
only one (10%) of the neglect group. It could be
argued that the physical abusers were acting on their
post-childhood learning of how to handle conflict by
resorting to physical abuse. None of these physical
abusers was now caring for their father and all were
redirecting their anger onto a dependant.
Furthermore, no other abusive relationships were
reported by this group. Interestingly, the one subject in
 Risk factors for elder maltreatment 59

TABLE 2. Carers with risk factor characteristics present in the abuse and neglect groups (%)

Abuse Neglect Total

(n=9) (n=10) (N=19)

Elderly dependant aged over 75 years 100 100 100

Carer lives constantly with their elderly dependant 100 100 100
An inexperienced or unwilling caregiver (CCI score 55+) 55 80 68
A carer who has high expectations of their elderly dependant
(CCI score 20 or below) 0 0 0
A caregiver who has relationship conflict with victim and often exhibits
hostile, threatening and/or aggressive acts (CTS score 17+) 66** 0 31
A caregiver who has other caring demands, e.g. from husband or children 44 50 47
A caregiver who is subject to high strain (SS score 26+) 66 90 78
A caregiver who is isolated 88 70 78
A caregiver who has poor physical health 0 0 0
A caregiver who has a history of mental health problems 66 70 68
A caregiver who has clinical depression (BDI score 30+) 100** 10 52
A caregiver who has an anxiety disorder (BAI score 20+) 22** 100 63
A caregiver who has a history of alcohol abuse 77** 10 42
A caregiver who has a history of drug abuse 0 0 0
A carer who was maltreated as a child by a father 66** 10 36

**p<0.01.

TABLE 3. Alcohol consumption in units per week for the neglect group who reported past abuse by her
physical abuse and neglect groups (numbers of subjects) father was now caring for him. She also reported
Alcohol use measured in units per week emotional and sexual abuse by him (see Table 4).
Three of the six risk factors measured by
Type of abuse Under 21 units Over 21 units psychometric assessments revealed significant
per week per week differences between the physical abuse and neglect
Physical abuse group
groups for conflict tactics, clinical depression and
(n = 9) 2 7 anxiety disorder. The three risk factors measured by
Neglect group the SS and CCI showed no significant differences
(n = 10) 9 1 between the two groups (see Table 2). These
differences were determined using a Mann± Whitney U
Note. Fisher’s exact test = 0.005, degrees of freedom =
1, p < 0.01. test on the raw scores.The average raw scores for each
of the psychometric assessments are presented in Table
5.
Raw mean CTS scores for the physical abuse group
TABLE 4. Abuse by father in childhood for physical
were 20.2 compared with 4.4 for the neglect group
abuse and neglect groups (number of subjects)
and were significantly different (p<0.01). It would
Abused by father in childhood? appear that the physical abuse group had a lot more
internalized anger than the neglect group, which they
Tye of abuse Yes No
then expressed in a physical way. No significant
Physical abuse group differences were found on the scores of the SS,
(n = 9) 6 3 suggesting that both groups felt under similar strain
Neglect group when caring for an elderly relative.
(n = 10) 1 9 Depression scores were significantly different
Note. Fisher’s exact test = 0.01, degrees of freedom = 1, between the physical abuse and neglect groups
p< 0.01. (p<0.01), with the physical abuse group having a raw
mean score of 47.8 compared with 18.8 for the
neglect group. The score for the physical abuse group
is indicative of severe clinical depression compared
TABLE 5. Summary of raw mean scores and significant with that of the neglect group, whose score suggests
differences between physical abuse and neglect group on mild depression.
referral to a clinical psychology department Anxiety scores for the two groups were also
Type of abuse CTS SS BDI BAI CCI significantly different; with a raw mean score for the
physical abuse group of 15.8 compared with 37 for
Physical abuse the neglect group. The score for the neglect group
(n=9) 20.2** 27.5 47.8** 15.8** 56.1 indicates an anxiety disorder while the score for the
Neglect
(n=10) 4.4 32.1 18.8 37.0 55.1 physical abuse group is within the normal range.
The CCI produced no significant differences
**p<0.01. between the two groups (raw mean scores of 56.1 for
60 A. M. Campbell Reay & K. D. Browne

the physical abuse group and 55.1 for the neglect
group). This suggests that both the groups found the
cost of caring equally high.
Discussion
no firm conclusions can be drawn concerning the
lack of significant differences in these small samples
of physical abuse and neglect groups. Future research
could consider a study to examine these tools more
closely.

This study was designed to investigate whether risk
factors would be significantly different between two
populations, one of which physically abused their
dependants and one of which neglected them. Alcohol
consumption and abuse by the father in childhood
were significant (chi-square test, p<0.01). The results
also showed that the physical abuse group and the
neglect group were significantly different on scores
measuring conflict, depression and anxiety as
measured by the CTS, BDI and BAI on referral to a
clinical psychology department (Mann± Whitney U
test, p<0.01).
It could be argued that these differences would be
expected, as subjects from each group have expressed
their maltreatment differently: actively for the physical
abuse group and passively for the neglect group. Anger
management could be a useful tool here to help the
physical abuse group deal with their anger more
appropriately but not necessarily the neglect group.
These clear differences between the abuse and neglect
groups indicate a lack of overlap between physical
abuse and neglect in elder maltreatment. This is in
contrast to child maltreatment, where physical abuse
and neglect often co-exist and frequently overlap (see
Browne & Herbert, 1997).
It could be suggested that the physical abuse group
may have internalized more of their anger and that
this is seen as depression and frequent use of hostile,
threatening and violent behaviour. These conflict
tactics are exacerbated by their heavy use of alcohol. It
would be interesting to consider whether alcohol
abuse counselling as well as anger management would
be useful to this physical abuse group.
The neglect group appear to act on their anxiety
and distress by avoidance of their caring role. It
would be interesting to consider for them an
education strategy which focuses on the nature of
caring, together with an anxiety management
package. The package would help teach them how to
deal with feelings of anxiety associated with caring
for their elderly dependant. As the validity and
reliability of the CCI and SS are not documented,
Future research on risk factors
Future research should also consider the differences
in victim characteristics for those who physically
abuse their dependants in comparison with those who
neglect them. Case histories which describe those at
risk of elder abuse and neglect have identified a
number of victim-based characteristics (Bennett &
Kingston, 1993; Steinmetz, 1988). These are outlined
in Table 6.
The use of risk factors in the identification of
maltreatment in those caring for their elderly
dependants concerns characteristics of the carer, the
victim and family circumstances.To assess their value
in screening populations of families where carers look
after elderly dependants, the prevalence of risk factors
in non-maltreating carers must be compared to that of
abusing and neglectful carers. In this way the
predictive value of each risk factor can be evaluated to
see which risk factors best discriminate between
maltreating and non-maltreating samples. Studies
using discriminant analysis methods to assess the
predictive value of risk factors have not been carried
out for elder abuse and neglect, although the
methodology is well established in studies of child
abuse and neglect (see Browne & Herbert, 1997).
The findings of this paper give only limited support
to the use of risk factors in the assessment of elderly
people and their carers, showing differences between
those who abuse and those who neglect their
dependants. Further work will compare these groups
to non-maltreating carers.
Implications for assessment
The results have highlighted the need to assess
previous family history, alcohol consumption, conflict
tactics, depression and anxiety in the carer, within a
broader approach to assessment. The factors are
important in assessment as they guide possible
intervention strategies to be employed.

TABLE 6. Victim characteristics as risk factors (adapted from Bennett & Kingston, 1993; Steinmetz, 1998)

An elderly person who is physically and/or mentally dependent on a caregiver

An elderly person who experiences poor communication between themselves and their caregiver
An elderly person who is seen as exhibiting demanding and/or aggressive behaviour
An elderly person who has abused the caregiver in the past
An elderly person who exhibits potentially provocative behaviours or condition on the part of the elderly relative
An elderly person who lives constantly with their caregiver
An elderly person who has a history of hospitalization, particularly of falls, and/or is `accident prone’
An elderly person who is frequently reluctant to report that abuse has taken place
An elderly person who becomes submissive, withdrawn or depressed in the presence of their suspected abuser
 Risk factors for elder maltreatment 61

TABLE 7. Comprehensive assessment for elder abuse and neglect

An account of the abusive behaviour itself: form, duration, frequency, intensity, antecedents, consequences and
maintaining factors
An account of the victim’s behavioural coping strategies: what helps, what does not help
The thoughts, attitudes and beliefs surrounding the abuse: intent of the abuser, reasons attributed by the victim for the
abuse, meaning attached to the abuse, cognitive coping strategies for dealing with the abuse
An account of psychological problems and psychological history for both abuser and victim, assessment of cognitive
and behavioural functioning
Details about the relationship between the abused and the abuser: history, changes, strengths, weaknesses,
dependency, individual roles within the relationship, power balance
The rules under which the family functions, and the communication systems within the family
A consideration of factors which may arouse suspicion of maltreatment

Any assessment should be tailored to the individual
client’s needs and should avoid stereotyping the older
person (Stevenson, 1988). Engaging the carer who is
involved in the abusive situation may require more
care and time than is usual. The abuser may restrict
access by being there, taking calls and diverting letters
(Breckman & Adelman, 1988). However, persistence
is required in view of the potentially serious nature of
the abusive relationship.
The assessment may vary depending on the
professionals concerned and the procedures adopted
but regardless of the agencies involved. Details of a
comprehensive assessment for families with elderly
people involving maltreatment are outlined in Table 7.
A multidisciplinary approach to assessment should
always be adopted, as medical, social and
psychological assessments are needed before further
action can be decided upon (Levin, 1988). In the
USA, specialist multidisciplinary assessment teams
have been set up to assess cases of elder maltreatment.
During any assessment procedure the needs and
wishes of the family, the carer and the victim need to
be established before further action can be decided
upon. This may be best achieved by means of a case
conference where the victim, his relatives and
members of the family are invited to attend and where
the co-ordination of services can be agreed and
reviewed at regular intervals (Kingston & Reay, 1995).
Conclusions
In conclusion, an examination of the risk factors
associated with physical abusers and those who
neglect their elderly dependants suggests that heavy
alcohol consumption and past childhood abuse by
fathers were likely to lead to physical abuse.
Significantly higher conflict and depression scores
were also present in the physical abuse group, while
the neglect group had significantly higher anxiety
scores. It should be acknowledged that this study is
based on a small sample derived from health
services (rather than social services), which may
create unacceptable bias. Despite this, significant
differences between those carers who physically abuse
their elderly dependants and those who neglect them
were evident. Therefore it is tentatively suggested
that these findings should be incorporated at least
into health service assessments of the risk of abuse
or neglect of elderly people by their carers in
domestic settings.
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