autism is a complex disorder in the pre-hospital setting ...ems.aanet.org/info/autism...
TRANSCRIPT
Autism AwarenessAutism Awareness
Autism is a complex disorderIn the pre-hospital setting, it may not be obvious if
the patient is experiencing an autism related symptom or another condition
Autism is a complex disorderIn the pre-hospital setting, it may not be obvious if
the patient is experiencing an autism related symptom or another condition
Autism SpectrumAutism Spectrum
AutismAutistic spectrumPDD, pervasive development disorderRett’s disorder 1:15,000Childhood disintegrative disorder 1:100,000Asperger’s syndromePDD - NOS
AutismAutistic spectrumPDD, pervasive development disorderRett’s disorder 1:15,000Childhood disintegrative disorder 1:100,000Asperger’s syndromePDD - NOS
Causes AutismCauses Autism
1st identified in 1943Cause remains unknownGenetic componentPossible external or environmental triggersDietary – Nutritional – GutVaccine?Autism is NOT caused by bad parenting
1st identified in 1943Cause remains unknownGenetic componentPossible external or environmental triggersDietary – Nutritional – GutVaccine?Autism is NOT caused by bad parenting
Prevalence of AutismPrevalence of Autism
1 in 150 births in the U.S. 1.5 million Americans have some form of Autism and it’s on the rise!Growing at a rate of 10-17% per year Today, 50 families in America will find out their child has AutismIncreased rates in boys (4-8x)Lasts a lifetime
1 in 150 births in the U.S. 1.5 million Americans have some form of Autism and it’s on the rise!Growing at a rate of 10-17% per year Today, 50 families in America will find out their child has AutismIncreased rates in boys (4-8x)Lasts a lifetime
CDC, 2007
PathophysiologyPathophysiology
Despite extensive investigation, no consistent pattern of the cause of autism has emerged.
In fact, more than 60 different disease entities have been shown to be likely causes of autism, including genetic, infectious, endocrine, toxic, and space-occupying etiologies.
Despite extensive investigation, no consistent pattern of the cause of autism has emerged.
In fact, more than 60 different disease entities have been shown to be likely causes of autism, including genetic, infectious, endocrine, toxic, and space-occupying etiologies.
PathophysiologyPathophysiology
Autism is a complex developmental disability that typically appears during the first three years of life and is the result of a neurological disorder that affects the normal functioning of the brain, impacting development in the areas of social interaction, behavior and communication skills.
Autism is a complex developmental disability that typically appears during the first three years of life and is the result of a neurological disorder that affects the normal functioning of the brain, impacting development in the areas of social interaction, behavior and communication skills.
Differential Diagnosis Differential Diagnosis
Fragile X – 5%PhenylketonuriaOther mental retardation – 9:1,000Selective mutismExpressive language disorderCongenital deafnessCongenital blindnessSchizoid personality disorder
Fragile X – 5%PhenylketonuriaOther mental retardation – 9:1,000Selective mutismExpressive language disorderCongenital deafnessCongenital blindnessSchizoid personality disorder
Signs & Symptoms AutismSigns & Symptoms AutismSpins objects; sustained odd playAloof manner; difficulty mixing with othersRepetitive movements; hand flappingLaughs, cries, shows distress – no clear reasonLittle or no eye contact; may not want cuddlingUneven gross – fine motor skillsSevere language defectsInsists on sameness; inflexible to routinesInappropriate attachment to objectsNoticeable physical - Over-or under-activityOver-or under sensitivity to pain, light or sounds
Spins objects; sustained odd playAloof manner; difficulty mixing with othersRepetitive movements; hand flappingLaughs, cries, shows distress – no clear reasonLittle or no eye contact; may not want cuddlingUneven gross – fine motor skillsSevere language defectsInsists on sameness; inflexible to routinesInappropriate attachment to objectsNoticeable physical - Over-or under-activityOver-or under sensitivity to pain, light or sounds
Signs & Symptoms AutismSigns & Symptoms Autism
Time Related Red Flags:No babbling by 12 months of ageNo pointing or gesturing by 12 months of ageNo single words by 16 months of ageNo two word spontaneous phrases by 24 months of ageAny loss of language at any time
Time Related Red Flags:No babbling by 12 months of ageNo pointing or gesturing by 12 months of ageNo single words by 16 months of ageNo two word spontaneous phrases by 24 months of ageAny loss of language at any time
A Spectrum ConditionA Spectrum Condition
Low & High functioning
Middle functioning?
Independence level?Dependent on a caregiver for life?
Public safety & criminal justice risks
Low & High functioning
Middle functioning?
Independence level?Dependent on a caregiver for life?
Public safety & criminal justice risks
Autism DiagnosisAutism Diagnosis
Typically appears by age 3Diagnosis is based on observation of the person’s; communication, behavior and development levelNo current medical testsMany behaviors shared by other disorders, so medical evaluation must be done to rule out other disabilities
Typically appears by age 3Diagnosis is based on observation of the person’s; communication, behavior and development levelNo current medical testsMany behaviors shared by other disorders, so medical evaluation must be done to rule out other disabilities
Treatments AutismTreatments Autism
Highly structured, specialized education programsMedication – symptoms not a cureOccupational, Physical therapies, Speech and Sensory therapiesNutritional, dietary restrictionsAlternative medicine approach
Highly structured, specialized education programsMedication – symptoms not a cureOccupational, Physical therapies, Speech and Sensory therapiesNutritional, dietary restrictionsAlternative medicine approach
Common Medication for AutismCommon Medication for Autism
SSRIs - Celexa, Prozac, and Zoloft. The high rate of effectiveness for depression, anxiety, and obsessive, stereotypical behaviors.Antipsychotic medications - such as haloperidol (Haldol), risperidone (Risperdal), Seroquel and thioridazine work by changing the effects of brain chemicals. They may help decrease problem behaviors that can occur with autism. Clonidine (Catapres), LithiumAnticonvulsants (carbamazepine), [Carbatrol, Epitol, Tegretol], valproic acid [such as Depakene]).
SSRIs - Celexa, Prozac, and Zoloft. The high rate of effectiveness for depression, anxiety, and obsessive, stereotypical behaviors.Antipsychotic medications - such as haloperidol (Haldol), risperidone (Risperdal), Seroquel and thioridazine work by changing the effects of brain chemicals. They may help decrease problem behaviors that can occur with autism. Clonidine (Catapres), LithiumAnticonvulsants (carbamazepine), [Carbatrol, Epitol, Tegretol], valproic acid [such as Depakene]).
Safety RisksSafety Risks
Accompanying medical conditionsMedication requirementsBehaviors draw attention – Increased 911 responseHigh pain threshold, may not recognize dangerSensory issuesSelf stimulating behaviors & attachmentsWandering issues
Accompanying medical conditionsMedication requirementsBehaviors draw attention – Increased 911 responseHigh pain threshold, may not recognize dangerSensory issuesSelf stimulating behaviors & attachmentsWandering issues
Changes in RoutineChanges in Routine
May cause behavioral outbursts, agitation and aggressiveness
911 response to residenceCare provider missing, illness, accidentExtreme reaction
May cause behavioral outbursts, agitation and aggressiveness
911 response to residenceCare provider missing, illness, accidentExtreme reaction
Common Reasons for ResponseCommon Reasons for Response
In an area where no one knows him or herParent or caregiver action misinterpretedCaregiver becomes incapacitatedRetail settingBehavior becomes escalatedMedical emergency, fire or natural disaster
In an area where no one knows him or herParent or caregiver action misinterpretedCaregiver becomes incapacitatedRetail settingBehavior becomes escalatedMedical emergency, fire or natural disaster
Response RisksResponse Risks
May not respond to follow commandsMay invade your personal spaceExtreme reactions to changeMay not answer questions appropriatelyParents or caregivers unprepared for emergencySkills gap to recognize – We are here to help
May not respond to follow commandsMay invade your personal spaceExtreme reactions to changeMay not answer questions appropriatelyParents or caregivers unprepared for emergencySkills gap to recognize – We are here to help
A Look at AutismA Look at Autism
Initial training deficitAutism recognitionDifferentiate between
Mental illnessTBIDeaf/blindMRCP
Initial training deficitAutism recognitionDifferentiate between
Mental illnessTBIDeaf/blindMRCP
Body Movements & BehaviorsBody Movements & Behaviors
Hand flappingUnusual arm movements frequently when happy or excitedBasic gestures like waving hello or good bye –may not make sense to a child with autismPrefer to be left aloneMotor ticsHyperactivityTantrums
Hand flappingUnusual arm movements frequently when happy or excitedBasic gestures like waving hello or good bye –may not make sense to a child with autismPrefer to be left aloneMotor ticsHyperactivityTantrums
Reactions to StimuliReactions to Stimuli
Wide spectrum that appear to be abnormally over or under active
Textures normally considered soft - PainfulOdors that are pleasing – may result in gaggingNormal sounds; vacuum, motor cycle – may be upsetting or even painfulSelf injurious behaviors – may be calming, soothing
Wide spectrum that appear to be abnormally over or under active
Textures normally considered soft - PainfulOdors that are pleasing – may result in gaggingNormal sounds; vacuum, motor cycle – may be upsetting or even painfulSelf injurious behaviors – may be calming, soothing
Self Inflicted - InjuriousSelf Inflicted - Injurious
Banging of the headRocking or lurching bodySkin pickingSelf bitingHead punching – slappingHead/body to object bangingPoking themselvesNail – hair removalTeeth banging
Banging of the headRocking or lurching bodySkin pickingSelf bitingHead punching – slappingHead/body to object bangingPoking themselvesNail – hair removalTeeth banging
Autism Behavior When Sick or Injured
Autism Behavior When Sick or Injured
Atypical response to pain or physical injuryInstead of crying or running to a caregiver, might continue activity in which resulted in the injuryMood alteration, may be the only clueIn some cases, the child appears to be “calmer,” this may be the only flag to illness or injury
Atypical response to pain or physical injuryInstead of crying or running to a caregiver, might continue activity in which resulted in the injuryMood alteration, may be the only clueIn some cases, the child appears to be “calmer,” this may be the only flag to illness or injury
Responding to Autism Related Emergency
Responding to Autism Related Emergency
Approach in a quiet, non-threateningSeek and use available information from persons on sceneTalk calmlyUse simple & clear instructionsAllow for delayed responseMay need to rephrase and repeat questions
Approach in a quiet, non-threateningSeek and use available information from persons on sceneTalk calmlyUse simple & clear instructionsAllow for delayed responseMay need to rephrase and repeat questions
Ask if the person has an ID cardAvoid touching if possibleEvaluate for injuriesMaintain safe distancesBe alert for sudden outburstsBe aware of sensory issues – fight or flightResist impulse to act quickly
Ask if the person has an ID cardAvoid touching if possibleEvaluate for injuriesMaintain safe distancesBe alert for sudden outburstsBe aware of sensory issues – fight or flightResist impulse to act quickly
Is Sensory Over-StimulationA Factor?
Is Sensory Over-StimulationA Factor?
Look for outward behaviors
Move the person to a QUIET place
Calm creates clam
Look for outward behaviors
Move the person to a QUIET place
Calm creates clam
Reduce Sensory InfluencesReduce Sensory Influences
Sirens, Lights, Radios & Portables
Crowds
Odors
Touch
Sirens, Lights, Radios & Portables
Crowds
Odors
Touch
De-escalationDe-escalation
Use time, don’t rush it
Use space, posture and positioning – buffers
Best approach to avoid litigation - media
Use time, don’t rush it
Use space, posture and positioning – buffers
Best approach to avoid litigation - media
De-escalation - CommunicationDe-escalation - Communication
They may not understand request –commandNon-verbals, body language - no clue!Attracted to shiny objects, pens – may reach or grab for themSensory overload – AnxietyCommunication – Verbal vs. Pictures
They may not understand request –commandNon-verbals, body language - no clue!Attracted to shiny objects, pens – may reach or grab for themSensory overload – AnxietyCommunication – Verbal vs. Pictures
Diffuse the SituationDiffuse the Situation
Back upNon-threatening positioningContact resourcesFamily contactFamiliar object they likeLast resort – You may need to restrain
Back upNon-threatening positioningContact resourcesFamily contactFamiliar object they likeLast resort – You may need to restrain
Tips Behavior Specialist
Tips Behavior Specialist
“If you are a Firefighter – EMT who doesn’t know the child you are already behind the game!”Usually when an autisitic child engages in self-injurous behaviors there is a sensory issue going onThe person may be craving some tactile input such as; deep pressure or scratchesTouching a child in this state will set them off
“If you are a Firefighter – EMT who doesn’t know the child you are already behind the game!”Usually when an autisitic child engages in self-injurous behaviors there is a sensory issue going onThe person may be craving some tactile input such as; deep pressure or scratchesTouching a child in this state will set them off
RestraintRestraint
Restrain with knowledgeRestrain with adequate resourcesHypotonia, low muscle toneSeizuresPositional Asphyxia – position on sideContinued resistanceContinue to communicate & model
Restrain with knowledgeRestrain with adequate resourcesHypotonia, low muscle toneSeizuresPositional Asphyxia – position on sideContinued resistanceContinue to communicate & model
RestraintRestraint
The LEAST RESTRICTIVE MEANS OF CONTROL must be employed
Technically (and legally), verbal communication is the "least restrictive" means of control
The LEAST RESTRICTIVE MEANS OF CONTROL must be employed
Technically (and legally), verbal communication is the "least restrictive" means of control
Verbal De-escalation Can be Successful
Verbal De-escalation Can be Successful
"validates" the patient's feelings by verbally identifying the behaviors the patient is exhibiting,and attempts to help the patient recognize these behaviors as being threatening openly communicates, explaining everything that has occurred, everything that will occur,and why the imminent actions are required respects the patient's personal space
"validates" the patient's feelings by verbally identifying the behaviors the patient is exhibiting,and attempts to help the patient recognize these behaviors as being threatening openly communicates, explaining everything that has occurred, everything that will occur,and why the imminent actions are required respects the patient's personal space
RestraintRestraint
PHYSICAL CONTROL should occur ONLY after failure of verbal controlOnly "REASONABLE FORCE" may be used when applying physical control "REASONABLE FORCE" is also required to be a SAFE amount of Force Never hesitate to wait – at a safe distance for adequate assistance
PHYSICAL CONTROL should occur ONLY after failure of verbal controlOnly "REASONABLE FORCE" may be used when applying physical control "REASONABLE FORCE" is also required to be a SAFE amount of Force Never hesitate to wait – at a safe distance for adequate assistance
RestraintsRestraints
Positional AsphyxiaPositional Asphyxia
Unusual – exertive muscular activity, excessive lactic acid producedBody usually responds to correct by hyperventilating. Normal breathing impairedDepleted storage of sugar in the bodyState of extreme, excessive catecholamine production (Adrenalin OD). Weakens respiratory muscles even moreHeat & Heart stress – Increased 02 demandRespiratory muscles – 1st to FAIL
Unusual – exertive muscular activity, excessive lactic acid producedBody usually responds to correct by hyperventilating. Normal breathing impairedDepleted storage of sugar in the bodyState of extreme, excessive catecholamine production (Adrenalin OD). Weakens respiratory muscles even moreHeat & Heart stress – Increased 02 demandRespiratory muscles – 1st to FAIL
Dangerous WanderingDangerous Wandering
Leading cause of law enforcement contact911 calls
TrafficStranger in the house
Attraction to water!!!Alzheimer’s disease parallelWandering preventionProject Lifesaver
Leading cause of law enforcement contact911 calls
TrafficStranger in the house
Attraction to water!!!Alzheimer’s disease parallelWandering preventionProject Lifesaver
Checklist – Community ProgramChecklist – Community Program
Name, physical descriptionParents, other caregivers contact informationAttractions, locations, water sourcesSensory, medical issues and requirements, if anyMethod of communication, if non-verbal, best methodID wearLikes, dis-likes, approach and de-escalation techniquesCommunity Outreach – PD, FD, EMS
Name, physical descriptionParents, other caregivers contact informationAttractions, locations, water sourcesSensory, medical issues and requirements, if anyMethod of communication, if non-verbal, best methodID wearLikes, dis-likes, approach and de-escalation techniquesCommunity Outreach – PD, FD, EMS
ID & Information HandoutsID & Information Handouts
Photo IDBracelet, ankletClothing tagsTattoosInformational handout
preferences
Photo IDBracelet, ankletClothing tagsTattoosInformational handout
preferencesDavid Breault
1131 Hedgewood Lane
518-372-8735
http://tattooswithapurpose.com
Autism & AssessmentsAutism & Assessments
Take longer
Echolia
Produce misleading statements
Often victim of crimes
Take longer
Echolia
Produce misleading statements
Often victim of crimes
Processing InformationProcessing Information
Inability to quickly process and respondPoor listenerUnable to deduce what other are thinkingRepeats words, statementsBody language and mannerisms
Inability to quickly process and respondPoor listenerUnable to deduce what other are thinkingRepeats words, statementsBody language and mannerisms
Laugh or giggle inappropriatelySophisticated echulahaDifficulty recognizing slang terms or jokesVery concrete thinkers, truth slayersMay not recognize non-verbal clues
Laugh or giggle inappropriatelySophisticated echulahaDifficulty recognizing slang terms or jokesVery concrete thinkers, truth slayersMay not recognize non-verbal clues
Emergency Information FormsEmergency Information Forms
Need to be updated frequently!
Rescue TIPSRescue TIPSExpect anything0 – 100 MPHAdults just as likely to act like kids and hideCheck under beds, in closetsSensory issues –EquipmentBolt riskStim behaviors – in your personal space
Expect anything0 – 100 MPHAdults just as likely to act like kids and hideCheck under beds, in closetsSensory issues –EquipmentBolt riskStim behaviors – in your personal space
Rescue VideoRescue Video
Exterior & interior windows locked, nailed or barredPlexiglass or LexanwindowsFences may have locksHouse unkeptDoors locked from the insideFecal smearing
Exterior & interior windows locked, nailed or barredPlexiglass or LexanwindowsFences may have locksHouse unkeptDoors locked from the insideFecal smearing
Aerial RescueAerial Rescue
Use EXTREME Caution –Your Safety 1st
Consider platformPerson may aggress towards rescuerAlways assure your securedBolt risk after rescueAssign a person to stay with the patient
Use EXTREME Caution –Your Safety 1st
Consider platformPerson may aggress towards rescuerAlways assure your securedBolt risk after rescueAssign a person to stay with the patient
Emergency ResponseUpgrade Triage
Emergency ResponseUpgrade Triage
Use the parent – caregiver as a resource!Patients may jerk away from basic care 7 touchEvaluate thoroughly for secondary injuryTools, equipment for job may create sensory overloadEarly notification to EDQuiet space – odors – waiting roomSame provider – be flexibleDon’t assume all HCP know a lot about Autism
Use the parent – caregiver as a resource!Patients may jerk away from basic care 7 touchEvaluate thoroughly for secondary injuryTools, equipment for job may create sensory overloadEarly notification to EDQuiet space – odors – waiting roomSame provider – be flexibleDon’t assume all HCP know a lot about Autism
Communication ProblemsCommunication Problems
Language problem – expressive vs. receptiveTakes cues & clues from responderWill do what it takes to keep a friendMay produce a false assessment
Language problem – expressive vs. receptiveTakes cues & clues from responderWill do what it takes to keep a friendMay produce a false assessment
Communication SuccessCommunication Success
Avoid technical termsUse familiar people to introduce responderUse photos or visual aidsUse fine rote memory skills, ABA techniqueVerbal bullet pointsChronological list
Avoid technical termsUse familiar people to introduce responderUse photos or visual aidsUse fine rote memory skills, ABA techniqueVerbal bullet pointsChronological list
PECSPECS
Other Communication MethodsOther Communication Methods
Facilitated communicationComputer board
Sign languagePicturesWritten
Facilitated communicationComputer board
Sign languagePicturesWritten
Sexual AbuseSexual Abuse
Naïve often passive natureWomen especially vulnerableAdult care staff, family member or others encourage aberrant behavior, reward it or teach that it is normalEye contact
Avoid it, no social valueSex and sexuality education
Naïve often passive natureWomen especially vulnerableAdult care staff, family member or others encourage aberrant behavior, reward it or teach that it is normalEye contact
Avoid it, no social valueSex and sexuality education
Pre-hospital AssessmentPre-hospital Assessment
Assure Scene Safety!!!Assess environmentAny clues of PMH?Any signs of abuse?ABC’sGCS – What is the baseline, measurable…Vital signs – can be challenging, capillary refillHead to toe survey for injuries
Assure Scene Safety!!!Assess environmentAny clues of PMH?Any signs of abuse?ABC’sGCS – What is the baseline, measurable…Vital signs – can be challenging, capillary refillHead to toe survey for injuries
Assessment - AppearanceAssessment - Appearance
Person or Child found running around nakedBruising – injury, abuse, self-inflictedInjury patternsSensory issues – bandage, splint, stethescope
Person or Child found running around nakedBruising – injury, abuse, self-inflictedInjury patternsSensory issues – bandage, splint, stethescope
Tips for AssessmentTips for Assessment
Use parent, caregiver for resourceAsk “Yes/No” unrelated questions to determine dependabilityCheck that patient is not clued by the last thing heardAsk open ended questions, requiring narrative responseAllow time to respond – MORE than you thinkFollow your gut feeling
Use parent, caregiver for resourceAsk “Yes/No” unrelated questions to determine dependabilityCheck that patient is not clued by the last thing heardAsk open ended questions, requiring narrative responseAllow time to respond – MORE than you thinkFollow your gut feeling
EMS TreatmentEMS Treatment
AMS – consider all the causesAirway, Airway, AirwayRestrain as a last resort
Positional AsphyxiaParent, caregivers – Resource - ResourceBe flexible, make the differenceMedications – may have idiosyncrasy reaction
AMS – consider all the causesAirway, Airway, AirwayRestrain as a last resort
Positional AsphyxiaParent, caregivers – Resource - ResourceBe flexible, make the differenceMedications – may have idiosyncrasy reaction
Interactions With PersonsWith Autism
Interactions With PersonsWith Autism
Be calmTurn off or dim lightsGive extra spaceClose doors to reduce the noiseUse your body or objects to block line of sight of an object the person may be obsessed withRoom odorsOffer change of clothesControl temperatureSimple languageSpeak slowly
Be calmTurn off or dim lightsGive extra spaceClose doors to reduce the noiseUse your body or objects to block line of sight of an object the person may be obsessed withRoom odorsOffer change of clothesControl temperatureSimple languageSpeak slowly
Interactions With PersonsWith Autism
Interactions With PersonsWith Autism
Allow time for them to respondGive praise & encouragementBe flexible, be creativeMovement activities – engage themExercise caution with restraintRemember Positional Asphyxia – Check AIRWAY statusRemove extra people from the areaSeek additional resources
Allow time for them to respondGive praise & encouragementBe flexible, be creativeMovement activities – engage themExercise caution with restraintRemember Positional Asphyxia – Check AIRWAY statusRemove extra people from the areaSeek additional resources
AutismAutism
Imagine…..If you were unable to COMMUNICATEIf you were in PAIN but couldn’t tell anyoneIf you felt distracted, frustrated, obsessed, and frightened, but you didn’t know whyFeeling this way every day
Imagine….. Trying to live with anAutism Spectrum Disorder!
Imagine…..If you were unable to COMMUNICATEIf you were in PAIN but couldn’t tell anyoneIf you felt distracted, frustrated, obsessed, and frightened, but you didn’t know whyFeeling this way every day
Imagine….. Trying to live with anAutism Spectrum Disorder!
ReferencesReferencesDennis Debbaudt – Autism Risk Management, http://autismriskmanagement.com/Charly Miller - RESTRAINT ASPHYXIA the SILENT KILLER, http://www.charlydmiller.com/RA/restrasphyx01.htmlAutism Society of America, Defining Autism, Diagnosing Autism, Autism Characteristics, http://www.autism-society.orgWildwood School Schenectady NY - http://wildwood.edu/Center for Disease Control & Prevention. Autism Information Center. http://www.cdc.gov/ncbddd/dd/aic/about/#symptomsEmergency Medical Services. Breaking Down the Barriers, Paul Murphy, Chris Colwell MD, Gilbert Pineda MD. August 2006.
Dennis Debbaudt – Autism Risk Management, http://autismriskmanagement.com/Charly Miller - RESTRAINT ASPHYXIA the SILENT KILLER, http://www.charlydmiller.com/RA/restrasphyx01.htmlAutism Society of America, Defining Autism, Diagnosing Autism, Autism Characteristics, http://www.autism-society.orgWildwood School Schenectady NY - http://wildwood.edu/Center for Disease Control & Prevention. Autism Information Center. http://www.cdc.gov/ncbddd/dd/aic/about/#symptomsEmergency Medical Services. Breaking Down the Barriers, Paul Murphy, Chris Colwell MD, Gilbert Pineda MD. August 2006.
QuestionsQuestions
Thank You!Thank You!
Adult Care FacilitiesAdult Care Facilities
Work force underpaid; under trained?Attractive to abusers; easy access to victimsUnderreported: victim may not report incident or recognize the criminal actLack of credibility as victim - witness
Work force underpaid; under trained?Attractive to abusers; easy access to victimsUnderreported: victim may not report incident or recognize the criminal actLack of credibility as victim - witness