Elder Abuse Prior to completing this discussion, read the required Roberto (2016) article below

 

Evaluate the issue of elder abuse being sure to define the types of abuse, the ages most susceptible to abuse, and other relevant information pertinent to this complex issue.Support your thoughts with the required reading, and one other source of scholarly perspective and research from the field. Additionally, propose two solutions for aging adults that would help them achieve successful aging and prevent elder abuse, as well as identifying two resources that would help active caregivers avoid elder abuse. 

 

Add references/citations

 

Roberto 2016 article:

 

Note: This article is one of nine in the special issue, "Aging in America: Perspectives From Psychological Science," published in American Psychologist (May-June 2016). Karen A. Roberto and Deborah A. DiGilio provided scholarly lead for the special issue.

Since first identified in the mid-1970s as "granny bashing" (A. A. Baker, 1975), elder abuse has become a pressing concern throughout much of the world. Most recent estimates based on The National Elder Mistreatment Survey (Acierno, Hernandez-Tejada, Muzzy, & Steve, 2009) suggest that at least 10% of community-dwelling older adults in the United States, or approximately 4.3 million older persons, experience one or more forms of elder abuse annually (Kaplan & Pillemer, 2015). Prevalence rates among survey respondents were highest for self-reported financial abuse by a family member (5.2%), potential neglect by a caregiver (5.1%), and emotional abuse (4.5%). Substantially lower rates were found for self-reported physical abuse (1.6%) and sexual abuse (0.6%).

Researchers and practitioners alike consistently assert that a dramatic discrepancy exists between the actual prevalence of elder abuse and the number of elder abuse cases encountered by health and service providers as well as criminal justice authorities. Underestimation of elder abuse occurs because older victims do not discuss their situation with others and rarely report incidences to the authorities. For example, of the 4.5% of older adults in the national prevalence study who reported experiencing emotional abuse, 8% of the individuals reported the event to the police (Acierno et al., 2009). Reasons older adults give for not disclosing abuse include embarrassment (Kosberg, 2014), belief that they are responsible for what happened (Moon & Benton, 2000), worry that the perpetrator might harm them even more (Ziminski Pickering & Rempusheski, 2014), fear of being placed in a nursing home (Jackson & Hafemeister, 2014), not believing that help is available if they expose the abuse (DeLiema, Navarro, Enguidanos, & Wilber, 2015), acceptance of a long-standing abusive situation as one that must be tolerated (Teaster, Roberto, & Dugar, 2006), and not recognizing their situation as an abusive one (Dakin & Pearlmutter, 2009). Community members' reluctance to recognize elder abuse as a problem and hesitance to get involved, particularly when options for intervention are perceived to be lacking, also contributes to the underreporting of elder abuse (Roberto, Teaster, McPherson, Mancini, & Savla, 2015).

Acknowledging this widespread and growing social issue, the2015 White House Conference on Aging (2015) included elder abuse, neglect, and financial exploitation as one of its four priority topics. The purpose of this article is threefold: (a) to summarize current understanding of elder abuse including what constitutes elder abuse, risk factors for elder abuse, perpetrators of elder abuse, and outcomes of elder abuse; (b) to describe current assessment and intervention strategies to address elder abuse; and (c) to identify gaps in and future directions for elder abuse research, professional practice, and policy development. Primary attention is given to abuse of older adults living in the community. Elder abuse in long-term care settings (see Post et al., 2010) and elder self-neglect (seeDong, Simon, Mosqueda, & Evans, 2012), while of significant concern, are beyond the scope of this article.

Definitions of Elder Abuse

There is no consensus on the definition of elder abuse or standard term for elder abuse consistently used by the scientific and practice communities, advocates, or state and local governments. The lack of a uniformed definition of elder abuse stems back to when elder abuse first was being recognized and there were no federal mandates or incentives to compel states to use common definitions (Anetzberger, 2012). Although terms such as "elder abuse" (World Health Organization, 2002), "elder mistreatment" (Bonnie & Wallace, 2003), and "elder maltreatment" (World Health Organization, 2011) are often used interchangeably, the parameters of both the abuse and persons covered vary widely (Roberto, 2016). Such discrepancies create confusion in discriminating what is elder abuse, limits generalizing findings across studies, and prohibits identifying common courses for effective intervention (Henderson, Buchanan, & Fisher, 2002).

Regardless of terminology used, most definitions of elder abuse recognize five types of abuse: (a) physical abuse—use of physical force that may result in bodily injury, physical pain, or impairment; (b) sexual abuse—nonconsensual sexual contact of any kind; (c) psychological and emotional abuse—infliction of anguish, pain, or distress through verbal or nonverbal acts; (d)financial abuse and exploitation—illegal or improper use of an older person's funds, property, or assets; and (e) neglect and abandonment—intentional or unintentional refusal or failure to fulfill any part of a person's obligations or caregiving duties to an older adult (American Psychological Association, 2012;Table 1). Current scientific investigations tend to address either one or more types of abuse collectively or narrowly focus on one specific subtype of abuse (e.g., psychological abuse, sexual abuse). Yet evidence embedded within the research literature and practitioner reports suggest that older adults often experience more than one type of abuse simultaneously, that is, polyvictimization (Ramsey-Klawsnik & Heisler, 2014). In addition, behaviors associated with each type of abuse vary (National Center on Elder Abuse [NCEA], n.d.-b,Table 2) and are included selectively and inconsistently across studies of elder abuse.

 

Types of Elder Abuse and Frequently Associated Indicators of Abuse

 

 

Examples of Abusive Behaviors

Risk Factors Associated With Elder Abuse

A number of interacting factors contribute to a person's vulnerability to abuse in late life, including age, gender, race, ethnicity, living arrangements, cultural beliefs and values, as well as physical and cognitive impairments, social isolation, and loneliness. Much of the research on risk factors for elder abuse relies upon small, cross-sectional studies; does not include comparison groups; and does not differentiate type of abuse, identify discrete contributions of individual risk factors, or address how risk factors interacts to increase susceptibility to elder abuse (Roberto, 2016). As a result, empirical evidence for most risk factors for elder abuse is mixed (Johannesen & LoGiudice, 2013).

Age and Gender

National findings suggest that older adults aged 60 to 69 were more susceptible to abuse than older age groups (Acierno et al., 2009), whereas investigations focused on specific types of abuse (i.e., financial) identified adults age 75 and older as being particularly susceptible to abuse (Metlife Mature Market Institute, 2011). One possible reason for the different findings is that younger old adults more often live with a spouse or with adult children, the two groups that are the most likely abusers (Lachs & Pillemer, 2015). Conversely, living with a larger number of individuals other than a spouse is associated with an increased risk of abuse, especially financial abuse (Peterson et al., 2014). The association between age and risk of abuse also may be linked to a decline in functional health, which often occurs later in life and results in a greater dependence on others for care and a higher level of individual vulnerability (Amstadter, Cisler, et al., 2011a).

Although women are more often identified as victims of elder abuse than are men (Laumann, Leitsch, & Waite, 2008), greater longevity resulting in associated age-related changes and dependencies may contribute to older women's risk for abuse. The higher likelihood of experiencing family violence (Wisconsin Coalition Against Domestic Violence, 2009) may increase older women's risk for abuse, particularly physical and sexual abuse (Acierno et al., 2010). Recently, Kosberg (2014) argued against a gender bias in elder abuse, stating that older men have been deemed "invisible," in part because of the failure of older men to acknowledge and report abuse. Research focused specifically on elder abuse of older men (see Kosberg, 2007) suggests that elder abuse is not only a problem for older women—it adversely affects the lives of older men as well.

Race, Ethnicity, and Culture

Although racial or ethnic minority status is a frequently identified risk factor for elder abuse (Lachs, Williams, O'Brien, Hurst, & Horwitz, 1997), analysis of national data did not reveal significant race- and ethnicity-based differences in the prevalence of abuse (Hernandez-Tejada, Amstadter, Muzzy, & Acierno, 2013). Evidence exists that cultural norms and beliefs about abuse and tolerance for abusive behaviors intersect with race and ethnicity (Horsford, Parra-Cardona, Schiamberg, & Post, 2011; Moon & Benton, 2000) and socioeconomic status (Dakin & Pearlmutter, 2009) to increase risk for elder abuse. Focus group data revealed that African American and White older women with high socioeconomic status, as well as Latina older women, did not identify financial abuse as a type of elder abuse, whereas working-class White women did not identify verbal abuse as elder abuse (Dakin & Pearlmutter, 2009).

Cognitive Impairment

Cognitive impairment is perhaps the most agreed-upon risk factor for elder abuse. As cognitive abilities decline, the risk of all forms of elder abuse increases significantly (Dong, Simon, Rajan, & Evans, 2011). Financial capacity, defined as the ability to manage one's financial affairs in a manner consistent with self-interest, begins to diminish very early in the trajectory of cognitive impairment (Okonkwo, Wadley, Griffith, Ball, & Marson, 2006), placing older adults at risk particularly for financial abuse and exploitation. Compromises in judgment and decision-making capacity and the tendency to judge others' trustworthiness less stringently than younger individuals (Charles & Carstensen, 2010) may also increase older adults' susceptibility to undue influence, a tactic used by many perpetrators of elder abuse.

Social Support

Older adults' positive perceptions of, and engagement with, their informal social network has the potential to reduce the influence of other risk factors of abuse (Luo & Waite, 2011). Perceptions of low social support more than triple the likelihood that older adults reported any form of abuse (Acierno et al., 2009). Social isolation and negative social interactions have been associated with increased risk of elder abuse (Dong & Simon, 2008; Fulmer et al., 2005), whereas positive social support and social participation moderated the risk of abuse (Luo & Waite, 2011). Most recently, Schafer and Koltai (2015) provided additional evidence for the significance of social embeddedness for deterring elder abuse. They found that older adults with dense social support in which members knew one another had a lower risk of elder abuse, even when perpetrators were found within these close networks.

Perpetrators of Elder Abuse

The relationships between older adults and potential perpetrators of elder abuse is often cited as a contributing factor leading up to abuse (Roberto, 2016). Older adults typically know their perpetrators, who are usually family members (e.g., spouse, adult child, grandchildren, nieces/nephews), friends, and others they trust and rely upon for help and services. Outsiders often perceive alleged perpetrators as primary sources of support for older adults rather than individuals who are causing them harm. Beyond basic descriptive information, the empirical literature provides little information about perpetrators and their motivations for the abuse.

Spouse/partner abuse in late life can be viewed on a continuum from longstanding abuse within a single relationship to abuse that begins with a new relationship in later life. It often involves multiple forms of abuse, including physical harm, sexual assault, and psychological humiliation or intimidation. In longstanding abusive relationships, physical violence tends to decline with age, often replaced with new or intensified types of psychological and emotional abuse endured in earlier years (Mezey, Post, & Maxwell, 2002; Teaster et al., 2006). National prevalence studies support this contention, with spouses/partners identified in one fourth or more of situations involving verbal or emotional abuse (Acierno et al., 2009).

Interdependencies within late-life parent-child relationships may place the older adult at risk for abuse. Adult children who are abusive are often dependent on their parents for shelter, finances, and emotional support (Jackson & Hafemeister, 2012). Salient factors underlying dependency in adulthood includes addiction to alcohol, pain medications, or recreational drugs (Jogerst, Daly, Galloway, Zheng, & Xu, 2012); a history of mental or emotional illness (Acierno et al., 2009); and chronic unemployment (Jackson & Hafemeister, 2011). It is unlikely that any one of these factors precipitates elder abuse, but rather abuse within these relationships stems from a combination of multiple personal struggles. Conversely, when older persons are dependent on an adult child for their care, the potential for abuse also may escalate. The overwhelming majority of adult children provide appropriate care for their older parents; however, caregiving can become stressful and lead to potentially harmful or abusive behaviors (Amstadter, Zajac, et al., 2011b; Beach et al., 2005). However, compared with overwhelmed caregivers who often seek help to improve the situation, perpetrators with narcissistic and domineering personalities tend to be quick to espouse justifications for their abusive actions (Ramsey-Klawsnik, 2000).

Paid caregivers and other professionals in which a trusting relationship is expected (e.g., guardians, lawyers, investment counselors) also are perpetrators of elder abuse. These perpetrators are good at cultivating relationships; they are charming and attentive, while waiting to take advantage of the trusting relationship they establish with the older person. For example, in cases of financial abuse and exploitation presented in the media (Metlife Mature Market Institute, 2011), some perpetrators purported that, in return for providing assistance and care for the older adult, they were entitled to additional compensation (e.g., money, possessions). Other perpetrators had access to older adults' money and assets, and when an occasion presented itself, they availed themselves to the older adults' resources.

Outcomes of Elder Abuse

Elder abuse, in all its forms, has a profound impact on the health and psychological well-being of late-life victims. Although some markers of elder abuse are instantly obvious, such as injuries ranging from bruises and sprains, to broken bones and lost teeth, to severe brain trauma (Friedman, Avila, Tanouye, & Joseph, 2011), older victims often experience numerous adverse health effects that may not be immediately evident and persist long after the abuse has stopped (Bonomi, Anderson, Rivara, & Thompson, 2007). The long-term effects of elder abuse include new or exacerbated health problems and hospitalizations (Dong & Simon, 2013), premature institutionalization (Rovi, Chen, Vega, Johnson, & Mouton, 2009), and a hastened death (M. W. Baker et al., 2009; Dong et al., 2011).

The impact of sexual abuse, perhaps the most egregious and underreported type of elder abuse (Teaster & Roberto, 2004), has received less attention in the research literature than other types of abuse. In addition to the physical remnants of being sexually abused (e.g., genital injuries; human bite marks; bruising on the thighs, buttocks, breasts), older sexual abuse victims often exhibited substantial psychosocial indicators of trauma, including symptoms of posttraumatic stress disorder (Ramsey-Klawsnik, 2004). Bonomi et al. (2007) found that sexual intimate-partner violence exposure, alone or in combination with physical abuse, resulted in numerous adverse health effects that "persisted for many years after the abuse stopped" (p. 993), including a high likelihood of depression and poor social and mental functioning.

Psychological and emotional abuse is one of the most underreported yet damaging forms of elder abuse. The intangible nature of psychological abuse makes it difficult to quantify and often means it goes unrecognized, even by older victims themselves. Older adults who experience chronic emotional mistreatment often internalize their abuser's verbal aggression, which leads to increased physical health symptoms and behaviors indicative of anxiety and depression (Begle et al., 2011). While acknowledging that physical and sexual abuse impact victims' psychological health, Cisler, Begle, Amstadter, and Acierno (2012) suggested that emotional abuse may have a more potent and direct effect on mental health. Accounting for other known correlates of poor mental health in late life, they found psychological mistreatment to be a significant predictor of late-life negative emotional symptoms and functional impairment.

Often referred to as the "Crime of the 21st Century," financial abuse and exploitation costs older Americans nearly 3 billion dollars annually (Metlife Mature Market Institute, 2011). But the loss of financial resources and valued possessions of older victims extend far beyond the savings and material goods that are not easily recouped late in life. Financial abuse and exploitation "engenders health care inequities, fractures families, reduces available health care options . . . increases rates of mental health issues among elders [and] . . . invariably results in losses of human rights and dignity" (Metlife Mature Market Institute, 2011, p. 4).

Detection of Elder Abuse

Psychologists and others working in clinical practice often struggle with identifying whether an older client has experienced abuse and when to report suspected abuse (Mosqueda & Olsen, 2015). To date, there is no single gold-standard test to ascertain abuse, with numerous tools employed by both researchers and clinicians. A review of 26 empirical articles found that modified versions of the Conflict Tactics Scale (CTS; Straus, 1979) was the most commonly used measure to identify elder abuse (Sooryanarayana, Choo, & Hairi, 2013). The CTS has strong psychometric properties and focuses on the use of negotiation, physical assault, and psychological aggression in relationships. Reviews of measures for use primarily in clinical practice (Anthony, Lehning, Austin, & Peck, 2009; Fulmer, Guadagno, Bitondo Dyer, & Connolly, 2004; Pisani & Walsh, 2012) identified a number of screening and assessment instruments, none of which have gained widespread use. Moreover, the reliability and validity of most of the measures identified has yet to be established (Cooper, Selwood, & Livingston, 2008). Taking a more informal approach, Mosqueda and Olsen (2015) suggested that psychologists and other health care providers ask their older clients whom they suspect may be involved in an abusive situation a series of questions (e.g., "Are you afraid of anyone?" or "Is anyone mistreating you?"). The client's response will help clinicians determine the need to report suspected abuse or to pursue another course of therapeutic action (Zeranski & Halgin, 2011).

As mandatory reporters in most states—and in keeping with the American Psychological Association's (2010) ethics code's general principles of beneficence and nonmaleficence, and respect for people's rights and dignity—psychologists are responsible to report suspected elder abuse when they have "reasonable" cause to believe that an older adult is experiencing abuse or neglect (p. 296). However, the decision to take action and report any suspected case of elder abuse is a challenging balancing act between protecting the clients' personal well-being and respecting their dignity and self-determination to make their own decisions about their lives (Scheiderer, 2012; Zeranski & Halgin, 2011).

Once a report of suspected abuse is made, psychologists are not responsible for identifying ways in which to remedy the situation, but they do have continued responsibility to their client regardless if the client is the victim, perpetrator, or other party involved in the situation (Mosqueda & Olsen, 2015). Psychologists must strive to preserve the therapeutic relationship while taking action to protect the vulnerable older adult (Zeranski & Halgin, 2011). Although reporting suspected abuse is a legally mandated breach of confidentiality, determining if anyone else (e.g., client, family member) should be informed requires careful consideration (Mosqueda & Olsen, 2015).

Elder Abuse Interventions

Whenever a potential abusive situation is identified, either by the victim or by a third party, in most states, Adult Protective Services (APS) is the principle public agency responsible for investigating the situation occurring in the community (NCEA, n.d.-a). When APS receives a report of elder abuse, workers investigate and, if warranted, take action to ameliorate the situation with legal, medical, psychological, and social services. In nonemergency cases, APS cannot investigate alleged abuse without consent from the older individual or his or her caregiver or legal guardian, a court order, or a search warrant (Roby & Sullivan, 2001). If consent is denied, APS can petition the court for assistance upon showing of probable cause. Once abuse is substantiated, APS provides overall management of the case along with law enforcement and, in some cases, the judiciary system. Immediate response to the abusive situation may involve removing either the older victim or the perpetrator from the home and securing medical care, supportive services, and mental health services.

Mental Health Services

Once the situation is stabilized, older victims who are receptive to receiving help may benefit from psychological interventions to address the trauma, anxiety, and stress associated with abuse. A recent pilot study provided preliminary evidence for the feasibility of providing evidence-based psychotherapy for anxiety and depression at the same time that older adults were receiving mistreatment resolution services (Sirey et al., 2015). Most eligible clients (69 of 81; 85%) were willing to accept mental health services.

Therapeutic interventions used for postabuse treatment of elder abuse have included individual counseling, psychoeducational support groups, case management, and volunteer victim assistance services (Ploeg, Fear, Hutchison, MacMillan, & Bolan, 2009). Early studies often reported no differences between treatment and control groups, and in some cases, interventions were reported to have negative impacts for older victims (Davis & Medina-Ariza, 2001). Differences also have been reported in the effectiveness for different modes of intervention. For example, approximately 67% of older victims who received individual counseling primarily for psychological abuse self-reported improvements in their ability to cope with their situation, whereas no change was reported for 31% of the older adults; deterioration occurred for less than 2% of the participants (Alon & Berg-Warman, 2014). Conversely, 50% of support group participants self-reported better coping abilities, whereas the other participants did not. Methodological issues may explain some of the mixed findings across and within studies, including inclusion of small, selective samples; limited use of rigorously designed randomized clinical trials; lack of established and agreed upon outcome measures; and use of descriptive and bivariate evaluation strategies (Ploeg et al., 2009).

Multidisciplinary Teams

Many communities have created multidisciplinary teams (MDTs) comprising local professionals (e.g., physicians, social workers, law enforcement, APS workers) to work with, or on behalf of, older victims. Such teams offer an integrative and holistic approach to elder abuse by actively engaging multiple professional disciplines and perspectives in the prevention and intervention process. The primary function of MDTs is to offer expert consultation to service providers, identify service gaps and systems problems, advocate for change, provide training events, and coordinate investigations or care planning (Teaster, Nerenberg, & Stansbury, 2003). Although published information about MDTs is mostly anecdotal and descriptive, a recent empirical evaluation of a multidisciplinary model suggested that these models are indeed effective (Rizzo, Burnes, & Chalfy, 2015). Specifically, an examination of 250 randomly selected cases of elder abuse found that older adults' gender (female), marital status (married), and living arrangement (living with the perpetrator) were significant covariate predictors of unfavorable mistreatment status at case closure. Taking these variables into account, older persons who received intervention services from an integrated legal and social services team compared with outcomes of a social-work-only intervention had a greater reduction in mistreatment risk at case closure.

State and National Initiatives

State and national initiatives also have implemented interventions to prevent and alleviate elder abuse, yet vary considerably according to state and federal priorities. For example, the AARP Foundation's Elder Watch Colorado (AARP Foundation, n.d.) is a program in which the Attorney General Office addresses financial exploitation by providing information to, and coordinating efforts by, the state's law enforcement offices, adult protection and mental health agencies, and service organizations assisting older adults. With support from the Administration for Community Living's Administration on Aging unit, the NCEA (Administration for Community Living, n.d.) serves as a national resource center dedicated to the prevention of elder abuse, and operates as a multidisciplinary consortium of collaborators with expertise in elder abuse, neglect, and exploitation. The NCEA disseminates information to professionals and the public about elder abuse, and it provides technical assistance and training opportunities for professionals. The Training Resources on Elder Abuse (USC Department of Family Medicine and Geriatrics and the NCEA, n.d.) is a searchable web-based database of elder-abuse-related training materials. It features a variety of materials and resources created by organizations throughout the country, including a library of videos appropriate for training purposes.

Federal legislation and policy initiatives also have been put forth to support intervention efforts to prevent and respond to elder abuse. The most comprehensive federal bill to shed light on interventions for elder abuse is the Elder Justice Act of 2009 (2010). The intent of the Elder Justice Act intent is to provide federal resources to prevent, detect, treat, understand, intervene in, and, when appropriate, prosecute elder abuse, neglect, and exploitation. Specifically, the act provides for the establishment of the Elder Justice Coordinating Council, an advisory board, and forensic centers, as well as funding for improvements to long-term care, APS, and the long-term care ombudsman program. In 2014, the Departments of Justice and the Department of Health and Human Services issued the Elder Justice Roadmap (Departments of Justice & Department of Health and Human Services, 2014). Developed with input from hundreds of public and private stakeholders from across the country, this first national strategic plan for elder justice identifies the most critical direct services, education, policy, and research priorities and concrete opportunities for greater public and private investment and engagement in elder abuse issues.

New Directions for Psychological Science and Practice in Elder Abuse

Eradicating elder abuse requires multiple solutions—it needs to be a priority of psychologists working together on intervention efforts utilizing multiple players (e.g., general public, professional communities, government policymakers) in multiple settings (i.e., community, long-term care facilities). To date, elder abuse research has been hampered by methodological issues and other challenges associated with the complexity of elder abuse, including human subject protection rules, mandatory reporting obligations, participant access and recruitment, agency cooperation, and a paucity of federal and private funding (Pillemer et al., 2011).

To develop effective elder abuse preventive measures and intervention programs and services requires researchers and practitioners from the psychological sciences need to band together and collaborate with members of other disciplines. It will take concerted and sustained efforts from all professionals in the elder abuse space to resolve these issues and: 

1. Develop a universally accepted definition of what constitutes elder abuse that will provide greater understanding of the magnitude of elder abuse. Age needs to be considered as part of the definition. There currently is no standard age parameters for elder abuse, which impedes both the generalization of knowledge generated and the delivery of services.
2. Disentangle the individual, relational, cultural, and societal factors that place older adults at risk for elder abuse, particularly for ethnic and racial minority elders and other vulnerable groups (e.g., rural elders, older adults with cognitive impairment, frail elders), and identify the pathways of not only vulnerability for abuse but also protective factors that prevent elder abuse from occurring. Without meaningful risk factor data, the development of intervention strategies will languish.
3. Expand efforts to increase understanding about the perpetrators of elder abuse beyond demographic characteristics and descriptions of personal behaviors. This information is needed in order to develop, implement, and evaluate intervention protocols. Ultimately, reducing elder abuse requires better identification and treatment of its perpetrators.
4. Document the full range of costs and consequences of elder abuse for older adults, families, communities, and the nation. Elder abuse threatens the physical, psychological, social, and economic well-being of all involved, individually and collectively. But without documentation of the outcome of abuse, efforts to eliminate elder abuse will remain elusive.
5. Gather comprehensive, evidence-based data to determine which intervention strategies work best for specific groups of older adults and the cost-effectiveness of current and newly developed programs. This information is essential not only for older persons who experience abuse, but for the training of new clinicians and practitioners and for advocates seeking state and federal support for their implementation.