Balancing practicality and validity of elder abuse identification measures: using data from adult protective services investigations.

Background and Objectives. In testing a comprehensive decision support system for Adult Protective Services (APS), this study addressed two problems common in APS research and practice: the psychometric quality of the measures and measurement burden. Research Design and Methods. Data were generated on 1,472 APS cases over six months in two California counties using the Identification, Services and Outcomes (ISO) Matrix, a comprehensive decision support system for APS. The ISO Matrix uses Short-Forms developed from the Elder Abuse Decision Support System (EADSS). Mini-Forms were developed from the Short-Forms and tested in order to reduce measurement burden. Mini-Forms were developed on each measure using sensitivity and specificity of the items in predicting the criterion of substantiation (yes/no). Psychometric quality was addressed by estimating predictive validity and Cronbach's alpha of Short-Forms. Predictive validity and reliability were also estimated on the Mini-Forms as was their correlation with the Short-Forms. Results. On Short-Forms, good predictive validity was found for all measures except those that were very rare. Results for even shorter Mini-Forms were mixed, and some will require further research on their reliability and validity. Discussion and Implications. Short-Forms had good psychometric properties and some Mini-Forms did as well. Ongoing adoption by several California counties and Montana demonstrates the viability and sustainability of using the ISO Matrix for research and practice.

Can standardized measures provide helpful feedback about adult protective services substantiation? Pilot data from a short self-neglect assessment.

Can standardized assessment contribute to improving Adult Protective Services (APS) practice? In this exploratory study, San Francisco and Napa APS utilized a newly developed short self-neglect assessment to test how standardized measures provide information for substantiation decision making. Findings demonstrated satisfactory reliability and validity for the short self-neglect assessment, and analyses revealed important issues that could improve practice. Review of outliers revealed: (1) problems using the assessment tool, (2) misunderstandings of APS procedures, and (3) struggles navigating the case management system. These revelations could all be easily addressed in training. Caseworker's clinical judgment and experience also continue to have a place in complementing the use of the standardized assessment.

Elder Abuse Decision Support System: Field test outcomes, abuse measure validation, and lessons learned.

The Elder Abuse Decision Support System was designed to meet the critical need for improved methods for assessment and substantiation of elder mistreatment, using a web-based system with standardized measures. Six Illinois agencies participated in the field test. One-year pre/post analyses assessed substantiation results, using Illinois' standard investigation procedure as a comparison. Pre/post acceptability was assessed with caseworkers in focus groups with adult protective service staff. Validity of measures was assessed using Cronbach's alpha and receiver operator characteristic curve analyses with final substantiation decision as a criterion. Increased substantiation of abuse was found. Regarding acceptability, the two systems were found to have differing strengths and weaknesses. Outcome measures had high validity estimates, while focus groups indicated directions for improvement. This study was a successful proof of concept that data collected in the field would be useful for clinical purposes as well as for research.

Development of short-form measures to assess four types of elder mistreatment: Findings from an evidence-based study of APS elder abuse substantiation decisions.

Improving the standardization and efficiency of adult protective services (APS) investigations is a top priority in APS practice. Using data from the Elder Abuse Decision Support System (EADSS), we developed short-form measures of four types of elder abuse: financial, emotional/psychological, physical, and neglect. The EADSS data set contains 948 elder abuse cases (age 60+) with yes/no abuse substantiation decisions for each abuse type following a 30-day investigation. Item sensitivity/specificity analyses were conducted on long-form items with the substantiation decision for each abuse type as the criterion. Validity was further tested using receiver-operator characteristic (ROC) curve analysis, correlation with long forms and internal consistency. The four resulting short-form measures, containing 36 of the 82 original items, have validity similar to the original long forms. These short forms can be used to standardize and increase efficiency of APS investigations, and may also offer researchers new options for brief elder abuse assessments.

Observational measure of elder self-neglect.

The purpose of this study was to improve measurement of elder self-neglect by testing the psychometric properties of the Elder Self-Neglect Assessment (ESNA). Social workers, case managers, and adult protective services providers from 13 Illinois agencies completed a 77-item assessment for 215 clients suffering from self neglect. Analyses used Rasch item response theory and traditional validation approaches to test for dimensionality, model fit, and additional construct validation, resulting in a 62-item assessment. The ESNA met Rasch fit criteria with good internal consistency, item reliability, and construct validity. A 25-item short form also met Rasch criteria. A hierarchy of items associated with severity of abuse was produced by frequency of occurrence. ESNA indicators of self-neglect align into two broad categories: behavioral characteristics and environmental factors, which must be accounted for in a comprehensive evaluation. Theoretical refinements developed using the empirically generated item hierarchy may help to improve assessment and intervention.

Using the Rasch measurement model in psychometric analysis of the Family Effectiveness Measure.

BACKGROUND: Valid assessment of family functioning can play a vital role in optimizing client outcomes. Because family functioning is influenced by family structure, socioeconomic context, and culture, existing measures of family functioning-primarily developed with nuclear, middle-class European American families-may not be valid assessments of families in diverse populations. The Family Effectiveness Measure was developed to address this limitation. OBJECTIVES: The aim of this study was to test the Family Effectiveness Measure with data from a primarily low-income African American convenience sample using the Rasch measurement model. METHODS: A sample of 607 adult women completed the measure. Rasch analysis was used to assess unidimensionality, response category functioning, item fit, person reliability, differential item functioning by race and parental status, and item hierarchy. Criterion-related validity was tested using correlations with five other variables related to family functioning. RESULTS: The Family Effectiveness Measure measures two separate constructs: The Effective Family Functioning construct was a psychometrically sound measure of the target construct that was more efficient because of the deletion of 22 items. The Ineffective Family Functioning construct consisted of 16 of those deleted items but was not as strong psychometrically. Items in both constructs evidenced no differential item functioning by race. Criterion-related validity was supported for both. DISCUSSION: In contrast to the prevailing conceptualization that family functioning is a single construct, assessed by positively and negatively worded items, use of the Rasch analysis suggested the existence of two constructs. Whereas the Effective Family Functioning scale is a strong and efficient measure of family functioning, the Ineffective Family Functioning scale will require additional item development and psychometric testing.

Convivir (to Coexist) and Other Insights: Results From the Positive Aging for Latinos Study.

Many Latinos in the United States do not have access to culturally sensitive services to help them age well. We combined community-based participatory research with concept mapping methods to understand how a sample of community-dwelling Latino older adults view positive aging. Nine focus groups (N = 101) generated 85 non-repeating statements, which were used to produce a final map with 11 clusters, organized into four overarching regions: Convivir (To Coexist), Self-Sufficiency, Perspectives on Life, and Healthy Behaviors. Further analyses revealed three themes: (1) the importance of varied social connections, as conveyed by the region labeled Convivir; (2) a multifaceted understanding of "stability" that includes finances, relationships, and spirituality; and (3) the need for a mature mindset reflected in the thematic cluster Tomalo Suave (Take It Easy). Findings can inform the development of interventions for Latino older adults and the cultural adaptation of programs initially designed for non-Latinos.

Examining Adult Protective Services Outcomes: Services Associated With the Decrease of Mistreatment Differed by Elder Mistreatment Type.

BACKGROUND AND OBJECTIVES: Adult Protective Services (APS) are the frontline agencies investigating elder mistreatment and providing/coordinating postinvestigation services. Yet, their effectiveness in reducing different types of mistreatment in relation to services is unknown. This study aimed to address the knowledge gap by identifying services provided by mistreatment type, and examining the associations of services with mistreatment reduction. RESEARCH DESIGN AND METHODS: A pretest-post-test design was implemented using the Identification, Services, and Outcomes (ISO) Matrix to assess mistreatment levels during case investigation and at case closure after services were provided. San Francisco and Napa APS participated in a 6-month data collection. RESULTS: The 4 most prevalent types of mistreatment were examined: emotional, physical, financial abuse, and neglect by others. On average, level of mistreatment decreased across mistreatment types after APS intervention. Care/case management, mental health, and other services were most common, while specific services differed depending on type of mistreatment. Care/case management services were associated with physical and emotional abuse reduction, legal services further correlated with emotional abuse reduction; financial planning services were associated with financial abuse reduction; care/case management and other services were associated with neglect reduction. DISCUSSION AND IMPLICATIONS: This is the first study to address APS services by mistreatment type and the outcomes of services. Adoption of the ISO Matrix by APS programs opens the possibility of research and practice collaboration in APS outcomes research using a standardized approach.

Conceptual model and map of psychological abuse of older adults.

Psychological abuse of older adults is a hidden and pervasive problem that is not well conceptualized nor well measured. Goals. The goals were to (a) conceptualize psychological abuse using three-dimensional concept maps, and (b) develop theoretical models. Methods. Statements describing the construct were generated by local and national panels. These were sorted and rated using Concept Systems software whereby the concepts were depicted as a map. Results. The concept maps guided development of theoretical hierarchies. Significance. Theoretical models may help to develop measures to estimate prevalence better and may enable more precise screening for triage into appropriate interventions.

Conceptual model and map of financial exploitation of older adults.

This article describes the processes and outcomes of three-dimensional concept mapping to conceptualize financial exploitation of older adults. Statements were generated from a literature review and by local and national panels consisting of 16 experts in the field of financial exploitation. These statements were sorted and rated using Concept Systems software, which grouped the statements into clusters and depicted them as a map. Statements were grouped into six clusters, and ranked by the experts as follows in descending severity: (a) theft and scams, (b) financial victimization, (c) financial entitlement, (d) coercion, (e) signs of possible financial exploitation, and (f) money management difficulties. The hierarchical model can be used to identify elder financial exploitation and differentiate it from related but distinct areas of victimization. The severity hierarchy may be used to develop measures that will enable more precise screening for triage of clients into appropriate interventions.

Stakeholders' Ideas About Positive Aging for Latinos: A Conceptual Map.

Few studies explore the differences between diverse stakeholders' understandings of what constitutes "positive aging" for Latino older adults. To address this gap, we worked with a 20-member steering committee (SC) of community stakeholders to collect concept mapping data from 38 scholars and community workers. We generated 90 statements related to positive aging from the literature and produced concept maps based on four different stakeholder groups' ratings of them. All stakeholders prioritized "Financial Security," but scholars marked "Spirituality" as least important whereas community workers rated it second highest. The design of programs for Latino older adults should reflect such differences.

Abuser Risk Measure: Reports by Alleged Victims to Adult Protective Services.

BACKGROUND AND OBJECTIVES: Within the elder abuse field, research on the characteristics of the abusers is scant, and no validated measure of abuser risk exists. The purpose of this study was to develop and test the Abuser Risk Measure (ARM). RESEARCH DESIGN AND METHODS: The Rasch measurement model and traditional psychometrics were used on a sample of 425 elder abuse cases that completed an elder abuse investigation and had a substantiation decision (yes/no). All had usable ARM responses that were obtained primarily from the alleged victim. ARM construct/criterion validity was tested against four types of elder abuse using substantiation decision as the criterion. Item analyses guided the development of a full 21-item ARM measure and, subsequently, a short, 9-item screener. RESULTS: The 21-item ARM met the Rasch criteria. Although the screener was borderline on Rasch criteria, the combination of a good Cronbach's alpha with strong criterion validation provided a rationale for endorsing its validity. Both versions of the ARM were significantly and most strongly predictive of physical and emotional abuse, and significant for financial exploitation. While not significantly predictive of neglect alone, they were strongly and significantly predictive of total types of abuse. DISCUSSION AND IMPLICATIONS: This study was innovative in developing abuser risk items, analyzing client data, and generally supporting ARM validity for elder abuse. Theoretically, and now empirically, it is becoming clear that measures of abuser risk have an important role to play in both case assessment and in research.

Validation of the MedUseQ: A Self-Administered Screener for Older Adults to Assess Medication Use Problems.

BACKGROUND: Older adults taking multiple prescription and nonprescription drugs are at risk for medication use problems, yet there are few brief, self-administered screening tools designed specifically for them. OBJECTIVE: The study objective was to develop and validate a patient-centered screener for community-dwelling older adults. METHODS: In phase 1, a convenience sample of 57 stakeholders (older adults, pharmacists, nurses, and physicians) participated in concept mapping, using Concept System® Global MAXTM, to identify items for a questionnaire. In phase 2, a 40-item questionnaire was tested with a convenience sample of 377 adults and a 24-item version was tested with 306 older adults, aged 55 and older, using Rasch methodology. In phase 3, stakeholder focus groups provided feedback on the format of questionnaire materials and recommended strategies for addressing problems. RESULTS: The concept map contained 72 statements organized into 6 conceptual clusters or domains. The 24-item screener was unidimensional. Cronbach's alpha was .87, person reliability was acceptable (.74), and item reliability was high (.96). CONCLUSION: The MedUseQ is a validated, patient-centered tool targeting older adults that can be used to assess a wide range of medication use problems in clinical and community settings and to identify areas for education, intervention, or further assessment.

Examining the Role of Substance Abuse in Elder Mistreatment: Results From Mistreatment Investigations.

Substance abuse has long been identified as a risk factor for elder mistreatment, yet research on the topic remains sparse. This study tested hypotheses whether perpetrator and victim substance use problems were associated with financial exploitation, physical abuse, emotional abuse, and neglect versus no abuse. Cross-sectional data were collected on 948 cases with yes/no substantiation decisions where 357 cases had no abuse in elder mistreatment investigations. Hypotheses were tested using odds ratios, bivariate, and multiple linear regression analyses including a control for victim vulnerability. Of 948 alleged victims, 42 (4.4%) exhibited signs of substance use problems. Among the 323 alleged perpetrators, 87 (26.9%) were reported to have substance use problems. Substance use problems by alleged perpetrators were associated ( p < .01) with financial exploitation, physical abuse, and emotional abuse but not neglect. Substance use problems by alleged victims were associated with neglect, but not the other types. Alleged perpetrators with substance use problems tended to commit multiple forms of abuse, were male and not caregivers. Except for the findings on neglect, the associations with elder mistreatment were stronger for alleged perpetrators with substance use problems, than for alleged victims. Clarification of the role of perpetrator risk factors such as substance abuse should improve risk identification and subsequent intervention.

The Importance of Investigating Abuser Characteristics in Elder Emotional/Psychological Abuse: Results from Adult Protective Services Data.

OBJECTIVES: Elder emotional/psychological abuse is the infliction of mental anguish on older adults through verbal or non-verbal acts. Using indicators based on existing literature, theoretically important abuser characteristics and victim vulnerabilities were collected using the Elder Abuse Decision Support System (EADSS) to test a theory of emotional/psychological abuse. METHOD: Eight-hundred-and-ten alleged emotional/psychological abuse cases were investigated by caseworkers in six Illinois adult protective services (APS) agencies; 466 individuals endorsed at least one item on the Older Adult Psychological Abuse Measure (OAPAM). RESULTS: Bivariate ordinary linear regression results established that all abuser characteristics were predictive of emotional/psychological abuse scores. In the hierarchical regression model where abuser characteristics were entered after victim vulnerabilities, abuser characteristics predicted emotional/psychological abuse above and beyond victim vulnerabilities (ΔR2 = 0.349, p < .001). Abuser risk and abuser's negative attitudes towards victims remained as significant predictors in the final model. Post hoc analysis identified significant items of abuser risk and negative attitudes, including: an emotionally draining relationship between abuser and victim, abuser's poor temper control, and abuser's angry feelings towards victims. DISCUSSION: Abuser weaknesses and strengths as highlighted in the theoretical framework should be further investigated for future prevention and intervention in cases of emotional/psychological abuse.

Measuring money mismanagement among dually diagnosed clients.

Clients dually diagnosed with psychiatric and substance abuse disorders may be adversely affected if they mismanage their Social Security or public support benefits. Assistance managing funds, including assignment of a representative payee, is available but there are no objective assessments of money mismanagement. In this study, a Structured Clinical Interview for Money Mismanagement was administered twice at 1-week intervals to 46 clients receiving disability payments and was compared with clinician's judgment that the client was incapable of managing funds, the frequent basis for payee assignment by the Social Security Administration and Veterans Affairs. Clinician's judgment and structured interview were concordant on 71% of capability judgments. The interview had high test-retest reliability and was correlated with self-reported money mismanagement and global assessment of functioning scale scores, but clinician judgment was not associated with these measures. Results suggest that the interview is sensitive in detecting money mismanagement and raises questions concerning the validity of clinicians' judgments.

Relative precision, efficiency and construct validity of different starting and stopping rules for a computerized adaptive test: the GAIN substance problem scale.

Substance abuse treatment programs are being pressed to measure and make clinical decisions more efficiently about an increasing array of problems. This computerized adaptive testing (CAT) simulation examined the relative efficiency, precision and construct validity of different starting and stopping rules used to shorten the Global Appraisal of Individual Needs' (GAIN) Substance Problem Scale (SPS) and facilitate diagnosis based on it. Data came from 1,048 adolescents and adults referred to substance abuse treatment centers in 5 sites. CAT performance was evaluated using: (1) average standard errors, (2) average number of items, (3) bias in person measures, (4) root mean squared error of person measures, (5) Cohen's kappa to evaluate CAT classification compared to clinical classification, (6) correlation between CAT and full-scale measures, and (7) construct validity of CAT classification vs. clinical classification using correlations with five theoretically associated instruments. Results supported both CAT efficiency and validity.

Substance use disorder symptoms: evidence of differential item functioning by age.

This study examined the applicability of substance abuse diagnostic criteria for adolescents, young adults, and adults using the Global Appraisal of Individual Need's Substance Problems Scale (SPS) from 7,408 clients. Rasch analysis was used to: 1) evaluate whether the SPS operationalized a single reliable dimension, and 2) examine the extent to which the severity of each symptom and the overall test functioned the same or differently by age. Rasch analysis indicated that the SPS was unidimensional with a person reliability of .84. Eight symptoms were significantly different between adolescents and adults. Young adult calibrations tended to fall between adolescents and adults. Differential test functioning was clinically negligible for adolescents but resulted in about 7% more adults being classified as high need. These findings have theoretical implications for screening and treatment of adolescents vs. adults. SPS can be used across age groups though age-specific calibrations enable greater precision of measurement.

Randomized trial of psychiatric care with representative payeeship for persons with serious mental illness.

OBJECTIVES: This randomized clinical trial assessed whether a community-based representative payee program that was coordinated with psychiatric care from the Department of Veterans Affairs was more effective than customary treatment. METHODS: In the experimental condition representative payeeship was provided by a community agency that worked to enroll clients and coordinate payeeship with clinical care through communication with clinical staff. The control condition consisted of customary clinical care that included the typical availability of representative payeeship. Hypotheses were that, compared with the control group, the experimental group would experience greater enrollment in a representative payee program; improved residential status; improved quality of life, including fewer symptoms of mental illness; less substance abuse; and improved money management. Participants were interviewed at baseline and at six and 12 months. Outcomes were analyzed with analysis of covariance by using covariates from the baseline. RESULTS: A total of 184 participants were enrolled at baseline (94 in the experimental group and 90 in the control group). A total of 152 interviews were completed at six months, and 149 were completed at 12 months. At 12 months, 31 percent of patients in the experimental group and 14 percent of those in the control group were receiving representative payee services. At 12 months, significant positive effects were observed for the experimental group on enrollment in a representative payeeship, alcohol and drug use, quality of life, and money management. Residential status approached significance. CONCLUSIONS: Use of a coordinated representative payee program was found to be effective in improving outcomes at 12 months. Although this evidence supports the wider implementation of a coordinated representative payee program, only 31 percent of the experimental group had their money banked with a representative payee. Therefore, future studies should focus on achieving a better understanding of the causal components of the intervention.

Development of a Money Mismanagement Measure and cross-validation due to suspected range restriction.

A measure of the tendency to mismanage money was developed in an evaluation of a representative payee program for individuals with serious mental illnesses. A conceptual model was composed to guide item development, and items were tested, revised, added, and rejected in three waves of data collection. Rasch analyses were used to examine measurement properties. The resulting Money Mismanagement Measure (M3) consisted of 28 items with a Rasch person reliability at .72. Restriction of range was likely responsible for the low Rasch reliability. Validity analyses supported the construct validity of the M3. Subsequently, a cross-validation study was conducted on an untreated sample not as susceptible to range restriction. The M3 produced a Rasch person reliability = .85 with good validity. The M3 fills a gap that can facilitate research in the understudied area of money mismanagement.