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