Developing the theoretical understanding of elder abuse: a social exchange approach

Universidade do Minho Escola de Psicologia João Filipe Mendes Fundinho julho de 2022 Developing the Theoretical Understanding of Elder Abuse: A Social Exchange Approach João Filipe Mendes Fundinho Developing the Theoretical Understanding of Elder Abuse: A Social Exchange Approach UMinho|2022 João Filipe Mendes Fundinho julho de 2022 Developing the Theoretical Understanding of Elder Abuse: A Social Exchange Approach Trabalho efetuado sob a orientação do Professor Doutor José Ferreira-Alves Tese de Doutoramento Doutoramento em Psicologia Básica Universidade do Minho Escola de Psicologia ii DIREITOS DE AUTOR E CONDIÇÕES DE UTILIZAÇÃO DO TRABALHO POR TERCEIROS Este é um trabalho académico que pode ser utilizado por terceiros desde que respeitadas as regras e boas práticas internacionalmente aceites, no que concerne aos direitos de autor e direitos conexos. Assim, o presente trabalho pode ser utilizado nos termos previstos na licença abaixo indicada. Caso o utilizador necessite de permissão para poder fazer um uso do trabalho em condições não previstas no licenciamento indicado, deverá contactar o autor, através do RepositóriUM da Universidade do Minho. Licença concedida aos utilizadores deste trabalho Atribuição CC BY https://creativecommons.org/licenses/by/4.0/ iii Agradecimentos Esta tese representa um esforço longo e árduo de vários anos que não poderia ser desenvolvido sem o apoio de algumas pessoas e entidades. Como tal, gostaria de fazer alguns agradecimentos. Acima de tudo, devo agradecer ao Professor Doutor José Ferreira-Alves que aceitou orientar este trabalho. Durante todo este período o Professor Ferreira-Alves sempre me propôs novos desafios e me convidou para novos projetos. Mostrou não só ser um excelente orientador científico como também um extraordinário ser humano nos momentos mais difíceis. Foi o orientador e mentor que todos os doutorandos e jovens investigadores mereciam ter, só espero ter sido um aluno à altura. O meu mais profundo agradecimento. Quero expressar também um agradecimento ao grupo de investigação em envelhecimento e desenvolvimento do adulto pelas aprendizagens, discussão de ideias e pela oportunidade de partilhar com os alunos mais jovens algumas coisas que fui aprendendo ao longo deste percurso. Aqui gostaria de dar uma palavra de destaque para a Dra. Diana Cunha Pereira que aceitou o desafio de colaborar na elaboração da revisão sistemática que faz parte desta tese. Sem a sua ajuda esse artigo de que muito me orgulho seria completamente inalcançável. Muito obrigado, Diana! À Fundação para a Ciência e Tecnologia pelo financiamento 1 e ao Centro de investigação em Psicologia da Universidade do Minho por me ter acolhido durante este período. Um agradecimento também à Comissão de Acompanhamento do meu projeto de doutoramento, a Professora Doutora Ana Mesquita e o Professor Doutor Pedro Albuquerque, cuja ajuda foi preciosa para manter o foco na fase inicial deste trabalho. Um agradecimento também à Professora Doutora Ana Carolina Braz, à Professora Doutora Zilda Del-Prette e a Professor Doutor Almir Del-Prette, pela excelente colaboração. Um agradecimento muito especial aos meus participantes, não só pelos dados, mas também pela fantástica coleção de histórias que partilharam comigo. Um obrigado às instituições e centros de convívio que me acolheram durante a recolha de dados, facilitando o acesso aos participantes, apesar de a minha presença ser sempre disruptiva das suas normais atividades. Por fim, um agradecimento aos meus avós que, embora já cá não estejam todos, me despertaram o interesse para esta área. Um agradecimento profundo aos meus pais por todo o apoio e paciência e ao meu irmão por ser a única pessoa capaz de me distrair nos momentos de maior stress. A todos, um muito obrigado. 1 Bolsa de doutoramento referência PD/BD/105965/2014 iv STATEMENT OF INTEGRITY I hereby declare having conducted this academic work with integrity. I confirm that I have not used plagiarism or any form of undue use of information or falsification of results along the process leading to its elaboration. I further declare that I have fully acknowledged the Code of Ethical Conduct of the University of Minho. v Desenvolvendo a compreensão teórica dos maus-tratos a pessoas idosas: uma abordagem da troca social Os maus-tratos a pessoas idosas são um importante problema de saúde pública que afeta uma parte significativa da população. Apesar de existirem várias propostas teóricas para os maus-tratos, estas encontram-se pouco exploradas. A teoria das trocas sociais é uma teoria pouco desenvolvida e estudada no contexto dos maus-tratos a pessoas idosas, mas com um forte potencial integrativo. O principal objetivo desta tese é desenvolver, operacionalizar e testar uma formulação da teoria das trocas sociais aplicada aos maus-tratos a pessoas idosas. Num primeiro estudo, uma revisão sistemática da literatura, procurou-se sumariar o apoio empírico de seis teorias explicativas dos maus-tratos. Verificamos que todas apresentam evidência favorável. A partir desta revisão concluiu-se que existe uma necessidade de explorar novas interpretações destes modelos teóricos. A partir da análise dos princípios básicos da teoria das trocas sociais, formulou-se e operacionalizou-se uma nova proposta teórica. Esta proposta centra-se na hipótese geral de que o risco de maus-tratos é determinado pela disponibilidade de recursos pessoais e pelo poder/dependência na relação. Num segundo estudo, procedeu-se à adaptação e validação de uma medida de competências sociais, que nos permite medir um indicador de poder na relação. O estudo de validação revelou que a medida apresenta características psicométricas adequadas. Num terceiro estudo testamos a proposta teórica explorando a associação entre alguns recursos cognitivos da pessoa idosa e os maus-tratos. Exploramos também o papel moderador da funcionalidade e das competências sociais. Os resultados indicaram que a memória episódica, fluência fonémica e velocidade perceptual são bons preditores dos maus-tratos. A relação entre cognição e maus-tratos foi moderada pela funcionalidade e pelas competências sociais assertividade, defesa de opiniões e expressão de afeto positivo. No quarto estudo seguimos o mesmo paradigma, mas desta vez para explorar o papel dos recursos “reconhecimento de emoções” e “intuições morais”. Não foi encontrada relação entre o reconhecimento de emoções e os maus-tratos. Os resultados indicaram que a intuição moral dano/cuidado está associada a mais relatos de maus-tratos enquato a intuição autoridade/respeito se associa a menos. Tal como no terceiro estudo, estes efeitos foram moderados pela funcionalidade e competências sociais. Esta tese apresenta evidência favorável a uma conceptualização dos maus-tratos como troca social. A teoria das trocas socias apresenta-se como uma ferramenta promissora para a teorização, intervenção e prevenção dos maus-tratos a pessoas idosas. Palavras-chave: cognição, competências sociais, maus-tratos a pessoas idosas, moralidade, teoria das trocas sociais. vi Developing the Theoretical Understanding of Elder Abuse: A Social Exchange Approach Elder abuse is an important public health issue that affects a significant part of the population. Although there are several theoretical proposals for elder abuse, these are underexplored. Social exchange theory is an underdeveloped and poorly studied theory in the context of elder abuse, despite its strong integrative potential. The main objective of this thesis is to develop, operationalize and test a formulation of social exchange theory applied to elder abuse. In the first study, a systematic review of the literature, we sought to summarize the empirical support of six theories of elder abuse. We found that all of them present favourable evidence. From this review, we concluded that there is a need to explore new interpretations of these theoretical models. A new theoretical proposal was formulated and operationalised from the analysis of the basic principles of the theory of social exchanges. This proposal focuses on the general hypothesis that the risk of elder abuse is determined by the availability of personal resources and the power/dependence in the relationship. In the second study, we adapted and validated a measure of social skills, which allows us to measure an indicator of power in the relationship. The validation study revealed that the measure has adequate psychometric characteristics. In the third study, we tested our theoretical proposal by exploring the association between some cognitive resources of the older adult and abuse. We also explored the moderating role of functionality and social skills. The results indicated that episodic memory, phonemic fluency and perceptual speed are good predictors of elder abuse. The relationship between cognition and elder abuse was moderated by functionality and the social skills assertiveness, defence of opinions and expression of positive affect. In the fourth study, we followed the same paradigm, exploring the role of “emotion recognition” and “moral intuitions” as resources. No relationship was found between emotion recognition and elder abuse. The results indicated that the moral intuition of harm/care is associated with more reports of elder abuse, while the intuition of authority/respect is associated with less. As in the third study, these effects were moderated by functionality and social skills. This thesis presents favourable evidence for a conceptualization of elder abuse as a social exchange. Social exchange theory seems to be a promising tool for theorizing, intervening and preventing elder abuse. Keywords: cognition, elder abuse, morality, social exchange theory, social skills. vii List of Contents Agradecimentos .................................................................................................................................. iii Resumo............................................................................................................................................... v Abstract.............................................................................................................................................. vi Chapter I - Conceptual introduction and theoretical background ...................................... 1 Ageing as development ........................................................................................................................ 2 What is old age? ............................................................................................................................. 3 What changes as we approach old age? .......................................................................................... 4 Theoretical approaches to development in late adulthood ................................................................ 6 Erikson's stages of psychosocial development ............................................................................ 7 Socio-emotional Selectivity theory ............................................................................................... 8 Selective Optimization with Compensation .................................................................................. 8 What is elder abuse? ............................................................................................................................ 9 Defining abuse across time ............................................................................................................. 9 Types and forms of abuse ............................................................................................................ 12 Why does abuse in older age happen? .............................................................................................. 20 The importance of studying theoretical explanations for elder abuse ............................................. 21 Caregiver Stress Theory ............................................................................................................... 22 Psychopathology of the Caregiver ................................................................................................. 22 The feminist approach/Power and control theory ......................................................................... 23 Obstacles to theoretical development in elder abuse ..................................................................... 23 Lack of immediate practical implications ................................................................................. 23 Lack of interconnectedness between theories .......................................................................... 24 Explaining vs blaming ............................................................................................................. 24 Not one abuse, but many ........................................................................................................ 24 Social Exchange Theory – an alternative explanation ......................................................................... 25 Basic principles of social exchange theory .................................................................................... 25 The impact of ageing on social exchange ..................................................................................... 32 Social exchange theory and development in later adulthood .......................................................... 34 Applying Social Exchange to elder abuse ...................................................................................... 35 Types of abuse on a social exchange view .................................................................................... 37 Using the principles of social exchange to predict elder abuse .......................................................... 38 xiv List of Figures Appendix B - Supplementary material – Chapter IV Figure 1 - Conditional effect of perceptual speed on the total number of abusive behaviors at fixed values of dependency on daily organization tasks ........................................................................... 210 Figure 2 - Conditional effect of phonemic fluency on the number of emotionally abusive behaviors reported at fixed values of dependency on movement tasks ............................................................. 211 Figure 3 - Conditional effect of phonemic fluency on the number of emotionally abusive behaviors reported at fixed values of dependency on hygiene tasks ................................................................. 212 Figure 4 - Conditional effect of episodic memory on the number of emotionally abusive behaviors reported at fixed values of dependency on movement tasks ............................................................. 213 Figure 5 - Conditional effect of episodic memory on the number of emotionally abusive behaviors reported at fixed values of dependency on hygiene tasks ................................................................. 214 Figure 6 - Conditional effect of perceptual speed on the total number of financially abusive behaviors at fixed values of dependency on daily organization tasks .................................................................... 215 Figure 7 - Conditional effect of phonemic fluency on the number of financially abusive behaviors reported at fixed values of dependency on movement tasks ............................................................. 216 Figure 8 - Conditional effect of phonemic fluency on the number of financially abusive behaviors reported at fixed values of dependency on hygiene tasks ................................................................. 217 Figure 9 - Conditional effect of perceptual speed on the total number of behaviors that constitute neglect at fixed values of dependency on daily organization tasks .................................................... 218 Figure 10 - Conditional effect of phonemic fluency on the number of emotionally abusive behaviors at fixed values of the social skill defending interests and opinions ........................................................ 219 Figure 11 - Conditional effect of perceptual speed on the number of financially abusive behaviors at fixed values of the social skill coping assertively with risk ................................................................. 220 Figure 12 - Conditional effect of phonemic fluency on the number of financially abusive behaviors at fixed values of the social skill defending interests and opinions ........................................................ 221 Figure 13 - Conditional effect of perceptual speed on the total number of behaviors that constitute neglect at fixed values of the social skill self-expression of positive affect .......................................... 222 Figure 14 - Conditional effect of perceptual speed on the total number of behaviors that constitute neglect at fixed values of the social skill coping assertively with risk ................................................. 223 Figure 15 - Conditional effect of perceptual speed on the total number of behaviors that constitute neglect at fixed values of the social skill defending interests and opinions ........................................ 224 1 Chapter I Conceptual introduction and theoretical background 2 Ageing is a complex process encompassing biological, behavioural, and social changes. Changes and transformations are inevitable, and we will all go through them if we live long enough. For good and worse, I have witnessed these changes firsthand in my close relatives. For several years I watched dementia take my grandfather from a fully active, independent person to a completely dependent person, and I did my part, helping my family assist him. I learned many things from that experience, but there is something I will never forget, and that is the constant doubt if both me and my family were giving my grandfather the best of care. I could not conceive a scenario where any of us would intentionally cause him any harm. This personal experience is probably why I got captivated by the field of elder abuse in the first place. It seemed to me that not providing the best care practices would be abusive, and that doubt that made me question if we could care better also made me question if we were in any way being abusive. I started to wonder that perhaps people who commit elder abuse sometimes simply do not know how to care better and probably had the same doubts I had. This personal and family experience urged me to try to understand what elder abuse is and mainly why it happens. Understanding why it happens is paramount to prevent it and help dissipate some caregivers' insecurities. Following that quest is how I started to work on this thesis. And what a journey it has been. Throughout this document, I will share the more scientifically relevant parts of that journey. This introduction will start by summing up the more important concepts, changes and theories of ageing and development. Then, we will discuss the concept of elder abuse and its representations and then move to the theories of elder abuse. We will then examine in detail the theory that is the focus of this work, the social exchange theory, by analysing its core concepts and how it can be operationalized to explain elder abuse. This introduction will finish with a description of the thesis’ objectives and hypotheses and how the conducted studies tackle those challenges. Ageing as Development Ageing is a process that begins at birth and continues throughout life, although most authors who study older adulthood focus on the ageing processes that take place from the point of maturity (adulthood) onwards into later years (Erber, 2013, p. 7). Lifespan development studies the processes of acquisition, maintenance, quantitative or qualitative transformation, and eventual decline of psychological structures and functions across our whole life (P. B. Baltes, 1997). Developmental psychologists usually focus on specific periods of life, such as infancy, adolescence, or adulthood. When we consider the ageing process in older adults, we specifically talk about development in old age. The term "ageing" is usually the target of a negative stereotype, being typically associated with decline (Levy, 1996). However, development in 3 older adulthood is a process of change, with gains and losses, like any other developmental period (P. B. Baltes, 1987; Brandtstädter, 2006; Labouvie-Vief, 1982). However, these changes occur in a social context, giving way for the gains and losses to be differently valued by older adults and the society they belong to. Consequentially, ageing is also a social construction (Coleman & O’Hanlon, 2017, p. 1). For example, western cultures emphasise the losses of the ageing process over the gains, while other cultures value more the gains (Coleman & O’Hanlon, 2017, p. 3). These differences will provide different ageing experiences. Nevertheless, well-achieved development in old age, or successful ageing, is associated with a maximization of gains and minimization of losses (M. M. Baltes & Carstensen, 1996). To better understand the ageing process as part of development in old age, we need first to clarify what exactly is old age. Second, if development in old age is characterised by changes in terms of gains and losses, we need to understand what exactly changes as we go through old age. What is Old Age? When judging if someone has entered older adulthood, the criteria most frequently used is retirement age (OECD, 2019, p. 139), which is based on chronological age. Chronological age is given by the time elapsed since birth. However, many interpersonal variabilities in multiple areas make chronological age a not-so-good predictor of age-related changes, for example, in performance (Salthouse, 1986). In an attempt to account for individual variability in old age, many researchers adopted a threetier categorization of chronological age for ages 65 and over (Erber, 2013). In this categorization, old age is divided into three groups: young-old (65 to 74), old-old (75 to 84) and oldest-old (85 and over). This categorization may be useful as it seems to be related to health variables, like emergency department admissions tend to be higher in the oldest-old group (Lee et al., 2018). However, it does not clearly account for all individual variability as other studies find that the oldest-old also have higher selfperceptions of health than their young-old counterparts (Zikic et al., 2009). Therefore, it was necessary to develop other approaches to age. Besides chronological age, Erber (2013) presents four more conceptualisations of age. There is biological age, a measure derived from the number of years one is expected to live. This measure is both speculative and relative. There is no way to accurately predict the number of years of life that remains for any of us, so biological age is rooted in an estimate based on our physical appearance, organ function, and health in general. It is also a relative measure, for it is only useful to compare one person with his/her chronological-age peers. To account for functional variability, we can think about functional age, which refers to a person's competence in carrying on specific tasks. Again, this is also a relative way of measuring age and is very task-oriented. For example, 4 we can say that A is functionally younger than B in mobility tasks. As it is task-specific, within-subject variability is very frequent. For example, someone can be functionally young at math but not at go-karting. Then, psychological age refers to how well one uses cognitive, personal, and social skills to adapt to new and changing circumstances. The ability to remain flexible is associated with being psychologically young. Social age is related to conforming or not with societal expectations for the behaviour of members of a specific age group. For example, a 15-year-old is expected to be at school, a 30-year-old working a fulltime job, and an 80-year-old retired. A person might be viewed differently depending on how he/she chooses to comply with society's expectations for his/her age. All these age estimations contribute to the individual subjective feeling of how old one is. That is typically called subjective age, the age people think of themselves as being. Interestingly, adults usually think of themselves as younger than their chronological age (Rubin & Berntsen, 2006), a gap that widens in advanced age (Kotter-Gruhn et al., 2016). Although developmental psychology relies heavily on chronological age, it is often considered a poor system to measure age concerning developmental phenomena. Especially in old age, some authors suggest that perceived time left to live is a more important indicator than chronological age (Carstensen & Hershfield, 2021). Nevertheless, chronological age is always dragged into the conversation when we talk about when old age begins. Typically, the number 65 is the threshold to becoming an older adult. According to data from OECD, this boundary has been adopted as it is one of the more frequently used thresholds for retirement (OECD, 2019, p. 139). Though increases in retirement age have been planned across the globe (OECD, 2019, p. 140), this age milestone stuck. Due to age's subjective nature, this threshold cannot be set in stone. So, old age encompasses beliefs, expectations, and various biological, psychological, and social phenomena and variables. These facets entwine themselves with great complexity, giving rise to enormous individual variability in older adulthood, the last phase of the ageing process. What Changes as we Approach Old Age? As discussed, development through old age is a mixture of gains and losses in different systems. As ageing is influenced by context, it is no surprise that older adults are a very diverse group. Tracking the changes that occur in older adulthood can sometimes be challenging. It is, nevertheless, fundamental to understand what changes as we grow older to further understand any phenomena in old age. Agerelated changes occur in all domains: biological, psychological, and social. 5 Biological changes are, perhaps, more visible as they include skin drying and wrinkles appearing while the hair gets thin and grey (Erber, 2013, p. 85). Biological changes occur in all major organ systems, with a general tendency to decrease the efficiency of bodily functions. It is important to note that these changes do not happen all at once but gradually over time. These changes are not pathological but natural and tend to affect the quality of life slightly. Some health conditions tend to be more prevalent in advanced age, but they are instead the exception than the rule. Also, health conditions that significantly decrease quality of life usually appear only in the last years of life (Schilling et al., 2018). The more frequent example of cognitive changes associated with the ageing process is what is known as the “classic intellectual ageing pattern” (Botwinick, 1977), that is, the stability of the verbal IQ (often compared with crystallized intelligence) and the decline in the performance IQ (compared to fluid intelligence). Other cognitive changes occur in perception, with a decrease in reaction times (Hultsch et al., 2002), particularly in complex tasks (Tun & Lachman, 2008). Memory impairments are one of the most frequent concerns of older adults regarding ageing and their cognitive abilities (Dark-Freudeman et al., 2006). There are age-related differences in memory functioning, but these differences are specific to some mnesic structures. Older adults seem to have a smaller working memory capacity than younger adults, but the main age-related change seems to be in the speed necessary to perform complex manipulations (Salthouse, 1994). The ability to resist distractions also diminishes and impacts the use of working memory (McNab et al., 2015). Episodic memory, which accounts for events and experiences located in time, seems to decrease (Larrabee, 2019). Though some of these changes are expected with old age, it is worth mentioning that older adults with higher education, a more active lifestyle and better physical and mental health tend to have better memory functioning and faster reaction times (Erber, 2013, León et al., 2015). Training can improve older adults’ performance (Carretti et al., 2007; Light et al., 1996). There are also some changes regarding emotions throughout the lifespan. Research has shown that older adults present more positive affect and less negative affect than younger adults (Mroczek & Kolarz, 1998). Plus, positive affect seems to increase while negative affect decreases across the lifespan, but the relation is not linear and influenced by other variables such as gender (Mroczek & Kolarz, 1998). Ageing has been associated with significant improvements in social functioning (Luong et al., 2011). Older adults have typically smaller social networks (English & Carstensen, 2014). Social networks can be composed of friends, family members, neighbours or other peripheral contacts. The number of close partners remains stable across the lifespan. However, peripheral contacts diminish (English & Carstensen, 2014), showing a general preference for relationships with family members, close friends 6 and long-term partners. This preference puts the quality of relations before the number of relations (Bruine de Bruin et al., 2020). Close relationships are also related to more positive emotional experiences, which is frequently pointed to as the reason for investing in these relationships (English & Carstensen, 2014). Favouring close relationships is also associated with higher reports of well-being (Bruine de Bruin et al., 2020). Although the described changes, particularly the biological and cognitive changes, are more related to decline, they do not need to be impairing or lead to maladaptation. Lawton and Nahemow’s Press-Competence Model (Lawton, 1986; Nahemow, 2000) proposed individual competence and environmental pressure interact in a dynamic process to determine the individual’s level of adaptation. Both individual competencies and environmental pressures change with ageing. If environmental pressures greatly surpass individual competence, the individual can no longer maintain an acceptable degree of functioning, falling to maladaptive behaviour and negative affect. In opposition, if the environment offers no challenge, the individual falls into a state of passivity and helplessness, also leading to maladaptive behaviour and negative affect (Satariano, 2006). Finding a balance could mean keeping adaptive behaviours and positive affect, which can be done by keeping environmental pressure slightly below competence in the “zone of maximum comfort”. Alternatively, it could mean keeping environmental pressure slightly above competence and encouraging active behaviour in the “zone of maximum performance potential” (Satariano, 2006). The press-competence model shows a way in which age-related changes, including decline, do not lead to stagnation but, if balance is found, leave room for further development in old age. Theoretical Approaches to Development in Late Adulthood So far, we have discussed the more striking changes humans face as they approach old age. However, simply describing these changes lacks something if not coupled with an explanation about what we do with these changes and what directions they lead. Describing ageing as a process of gains and losses has been done quite a few times in this text. It is an idea that developmental psychologists like to point out with an astonishing frequency. In the previous sections, we described some of the losses and some of the gains associated with ageing. We would like to put these changes into context and briefly explore what we do with them. Is there something or some things that we aim to gain during our development into old age? Is there something we can afford to lose? How do we deal with these changes? Questions like these are at the heart of some theories of development in old age. In the following paragraphs, we will describe some theoretical perspectives on ageing and the adaptation to ageing, 7 namely Erikson’s theory of psychosocial development, socio-emotional selectivity theory and the selective optimization with compensation theory. As we will discuss later, these perspectives can be connected to the theory we choose to explore, putting social exchange theory into a developmental lens. Erikson's Stages of Psychosocial Development. Talking about development without mentioning Erik Erikson is like playing football without a ball. Erikson's conception of psychosocial development has been a frame of reference for so many development psychologists that it simply cannot be ignored. Erikson conceptualises development from a life-span perspective. We pass through different stages, from infancy to old age, each one with a defining developmental task. Each person faces their developmental challenges inserted in an environment with other persons who are also facing their own challenges (Erikson, 1963). Erikson’s theory describes eight stages of psychosocial development, each associated with a specific period in the lifespan (Erikson, 1963; Erikson & Erikson, 1998). In infancy, the primary challenge is to develop trust over mistrust. During childhood, the stages' focus is on autonomy, initiative and industry. Adolescence is characterised by the development of identity over identity confusion, and in young adulthood, the focus is on the search for intimacy over isolation. In middle adulthood, the central developmental theme is generativity. Erikson created the term to designate the interest to set up and guide the next generation. Latent to this concept is the idea of family growth and of contributing to one's society. The opposite of generativity would be stagnation, focusing on oneself and not others. But, for Erikson, the central developmental challenge of old age is ego integrity. Attaining integrity is the "acceptance of one's one and only life cycle as something that had to be and that, by necessity, permitted of no substitutions" (Erikson, 1963, p. 268). At the opposite end of integrity is despair, a feeling of failure in life paired with a lack of time to attempt alternative ways to reach integrity. The stages in Erikson's theory are conceived as hierarchical, meaning that facing each developmental task implies resolving the preceding stage (Erikson, 1963; Erikson & Erikson, 1998). Each developmental task is associated with the acquisition of specific psychological strengths (Erikson & Erikson, 1998). Moving from stage to stage across the life cycle will summate the acquired psychological strengths. So, in a sense, as the last stage, ego integrity reflects the balance and summation of the psychological strengths developed throughout the life cycle, coming together as a whole (Coleman & O’Hanlon, 2017, p. 13). Ego integrity is not only based on reflecting upon one's life, but it also implies accepting the society that will continue after death, a society that might surpass the values that have guided one's life. The capacity to accept death in light of what has passed and what might come to be after departing is central to Erikson's concept of ego integrity (Erikson, 1963, p. 269). However, the 8 physical and mental decline in the years closest to death may challenge the maintenance of ego integrity. In light of this, a ninth stage was proposed as an addition to Erikson’s theory, where the dystonic outcome is given more salience than the tonic developmental outcome (Erikson & Erikson, 1998). Erikson’s model remains as influential as it has ever been. The proposal of generativity and integrity as the central developmental challenges of middle and old adulthood are still focal points in adult development and have become the basis for various other theories of development and ageing (Coleman & O’Hanlon, 2017). Socio-emotional Selectivity Theory. Carstensen's Socio-emotional selectivity theory (Carstensen, 1991, 2006; Carstensen et al., 1999) is one of the most influential theories of adult development. It shares a premise with disengagement theory, which gained influence in the ’60s and postulated that as adults grow into old age, they choose to distance themselves from their roles in society as society ceases to depend on them to perform those roles (Coleman & O’Hanlon, 2017). Socioemotional selectivity theory also claims a reduction in social interactions in old age but gives a different explanation. Socio-emotional selectivity theory postulates that the relative importance attributed to relationships and goals changes as we approach death (Carstensen, 1991). As we grow into old age, we come to value more relationships that promote well-being and contentment over relationships that may be useful. We grow to prioritize emotional goals over cognitive goals and well-being over knowledge acquisition (Carstensen et al., 1999). So, according to the social-emotional selectivity theory, disengagement in older adulthood has to do with different life goals, sprung from the perception that death draws closer (Carstensen, 1991). One of the main points extracted from this theoretical perspective is common with the Eriksonian view on development: goals change as we advance through the lifespan (Coleman & O’Hanlon, 2017). These changes are reflected in some aspects of the older adults’ social networks. Although younger adults’ and older adults’ social networks have similar structures, older adults tend to have fewer contacts and prioritize contact with close relatives. New relationships encompass a certain degree of uncertainty and are avoided. Relationships with close relatives with a history of past emotional investment have a greater probability of resulting in emotionally positive interactions. Choosing known and invested social partners shows a tendency to optimize relationships in favour of emotionally positive outcomes (Coleman & O’Hanlon, 2017). Selective Optimization with Compensation. Selective optimization with compensation is the most prominent theory of adaptation to old age. This theory, developed by Paul and Margaret Baltes (P. B. Baltes, 1987, 1997; P. B. Baltes & Baltes, 1990), defends a prototypical mechanism to achieve successful ageing by adapting to constraints posed by losses and optimizing favourable developmental 9 outcomes. According to this theory, successfully adapting to old age implies the use of three strategies (P. B. Baltes, 1997). The strategy “selection” refers to focusing efforts on tasks and goals for which skills remain high and, therefore, are very likely to have a positive outcome. The selection process is prompted by the anticipation of change or functional restriction and implies a continuous analysis and narrowing of behavioural options and goals to activities with high efficiency and enjoyability. The strategy “optimization” consists in focusing on behaviours that maximize quantity and quality of life. It involves an effort to acquire or improve performance in specific and more valued areas. This process can be reactive when used to adjust to new limitations or proactive when used to save resources from one task to a more valued task. "Compensation” is the adoption of new strategies to adjust to losses. This strategy is used to cope with losses or with the anticipation of losses. This strategy reflects the recognition of limitations or challenges and a need to keep performance at the desired level. Adopting these strategies aims ultimately to achieve successful ageing and allow the older adult to conduct his or her developmental tasks more efficiently (M. M. Baltes & Carstensen, 1996). This theory provides an important framework for conceptualizing behavioural change in old age. What is Elder Abuse? Defining Abuse Across Time As ageing is inevitable, stories of older adults being subject to abuse have been around for quite some time. One good example is given to us by the “Bard” himself. In William Shakespeare's "King Lear", old age and abuse are central themes, as the king, losing his mental acuity, is cast out by his daughters who were supposed to house him and care for him. As he accounted for it in this play, mistreatment of the elderly was probably a social issue in Shakespeare's time and probably even before. This story was allegedly inspired by a monarch in the mid-XII century, portrayed Historia regum Britanniae by Geoffrey of Monmouth (1100?-1154), a compendium of stories from legendary kings of Britain. Though the historical value of this source is questionable, it is beyond doubt that the theme introduced itself into the folklore of the region (Brain, 2019). To the scientific community, it took longer to start looking into this phenomenon. The first references in the scientific literature to mistreatment against older adults appeared in 1975 in a letter exchange in a medical journal. From their professional experience, two physicians realised that there were situations where older adults, particularly women, were physically abused and that this abuse was the result of improper care, for example, overmedication (Baker, 1975; Burston, 1975). These physicians saw this phenomenon as a poor reflection of their services that left people in need unattended and 16 explained by methodological, and measurement differences since this form of abuse gives way to much measurement variability. However, in the international studies that include Portugal, the prevalence is superior to other European countries, suggesting that there is a significant problem in this part of the world. Financial or material exploitation, often called financial abuse, can be defined as the improper, illegal, or unauthorised use of an older adult's funds, property, or assets. Abusive behaviours that fall into this category include stealing money, jewellery, or other values, forging signatures, and coercing or deceiving the older adult to sign documents or dispose of assets (National Center on Elder Abuse, 2015, p. 5). One of the key elements of this form of abuse is the relationship between older adults and perpetrators. To be considered elder abuse, a perpetrator is expected to be someone the older adult trusts, as stated in the general definition. The inclusion of financial scams explicitly aimed at older adults in this form of abuse is debatable. On the one hand, it can be argued that the scammers deceive and manipulate to build this relationship of trust and aim their scams specifically at older adults (Kemp & Mosqueda, 2005). On the other hand, it can be argued that the relationship built exclusively to scam the older adult can be considered artificial and that these scammers might target older adults and younger adults. Another argument that we find very compelling in favour of this last perspective is that one of the ends of financial abuse is getting financial control over the older adult by controlling his or her finances (National Center on Elder Abuse, 2015, p. 6). This point is more congruent with long-term relationships rather than with scammers. However, in any of these cases, older adults with less familial relations (single or without children) and cognitive difficulties are more frequently victims of this form of abuse (Garre-Olmo et al., 2009; Jackson & Hafemeister, 2011). It is estimated that 6.8% of older adults have experienced financial abuse, making this form of abuse one of the most prevalent (Yon et al., 2017). In Portugal, the prevalence of financial abuse is similar to other countries, but estimates vary considerably from study to study. While the AVOW study reported a prevalence of 16.5% (Ferreira-Alves & Santos, 2011), the Aging and Violence study reported a prevalence of 6.3% (Gil et al., 2015). This difference of more than 10% is troubling and difficult to explain. It is possible (if not probable) that some cultural aspects might influence the construction of measures of financial abuse, leading to these discrepancies. The fifth and last of the more agreed-upon forms of abuse is neglect. As previously discussed in the earlier definitions of elder abuse, neglect was the subject of some debate. In the earlier definitions, we would talk about elder abuse and neglect or mistreatment and neglect, defining neglect as something different from abuse (Mysyuk et al., 2013). However, in the later definitions, neglect is included inside 17 the larger conceptual umbrella of elder abuse and is considered a type of abuse (e.g., World Health Organization, 2002). Neglect can be defined as the failure of a person to fulfil his/her duty or obligations towards an older adult or to satisfy his/her needs, such as the activities of daily living, the instrumental activities of daily living and the need for physical and mental wellness (National Center on Elder Abuse, 2015, p. 10). Frequent examples are the failure to provide adequate care in any form, such as food, water, clothing, or shelter, and the failure to provide assistance, such as helping to move to/or from bed. One main characteristic helps distinguish this form of abuse from the others. While in other forms, abuse results from a perpetrator's action, in this case, abuse emergers from the absence of appropriate action or by actions that are insufficient in fulfilling the needs of the older adult. Consequently, determining who is the perpetrator of neglect can be very hard. Determining the person who would have a duty or obligation to the older adult can involve analysing legal aspects and even cultural, moral, political, and philosophical aspects. For instance, could an estranged adult child commit neglect? The main point is that it is not always easy to determine who is responsible for assisting an older adult who needs it. This complexity in identifying a perpetrator makes this form of abuse conceptually fascinating. An analysis of the support network would be essential to understand further how and when neglect happens. Despite these conceptual issues, several prevalence studies have been conducted. It is estimated that about 4.2% of older adults have experienced neglect (Yon et al., 2017). Specifically, in Portugal, prevalence rates vary from 0.4% (Gil et al., 2015) to 9.9% (Ferreira-Alves & Santos, 2011). Several arguments can be pointed out to explain this wide range of variation, methodological, conceptual, and so forth. However, this variability is enough to raise scepticism in all the prevalence numbers presented, and we firmly believe that conceptual issues are at play in this variance. The five types of abuse described so far are the more agreed upon and more frequently included in research and public-health statistics. However, some influential institutions and researchers consider more forms of abuse. One good example is another typology of abuse proposed by the NCEA from the USA, which adds self-neglect and abandonment (National Center on Elder Abuse, n.d.). Self-neglect is defined as the behaviour of an older adult that threatens his/her own health or well-being. It includes the failure to provide himself/herself with nourishment, clothing, hygiene, and so forth. This form of abuse excludes the cases where a mentally competent person willingly chooses not to take these self-caring measures. Abandonment is defined as the desertion of an older adult by an individual responsible for caring for him or her (National Center on Elder Abuse, n.d.). These two forms of abuse can be considered special cases of neglect. To be considered abandonment, an abusive situation fills all the criteria for neglect, so abandonment can be seen as neglecting all caring tasks. In the five-type nomenclature 18 proposed by NCEA, abandonment is considered a form of neglect (National Center on Elder Abuse, 2015, p. 10). Self-neglect can be a bit more tricky. By definition, self-neglect is perpetrated by the older adult to himself or herself, which directly conflicts with the general definition of abuse, where the perpetrator is another person. This assertion makes self-neglect conceptually debatable. Plus, in different cultures, there are different expectations about care. Research finds differences between cultural groups in which behaviours can be classified as self-neglectful (Filippo et al., 2007), thus supporting the claim that selfneglect is dependent on culture. It stands to reason that, in more individualistic societies, the inability to care for oneself could be labelled as self-neglect. Meanwhile, in more cooperative societies, if an older adult is not able to care for himself/herself, the responsibility of providing care falls on another's shoulders (a family member or the State), thus constituting neglect. As such, it comes as no surprise that selfneglect would fall under different scopes, depending on the culture (Braye et al., 2015). The summation of cultural differences with the overlap of these forms of abuse with neglect makes them debatable, and that may be why they are more controversial than other forms of abuse. Even less explored is a set of behaviours about the violation of personal rights, which probably would be better referred to as “denial of rights”. Even though the general definition of abuse more frequently adopted frames abuse as a violation of human or civil rights, this theme is seldomly adopted in the abuse typologies. Yes, it is considered that every form of abuse is a violation of human rights but are not all violations of human rights abusive? Denying privacy, autonomy, freedom, restricting visits, or isolating the older adult are examples of behaviours that would fall into this category and have been considered in some studies (Ferreira-Alves & Santos, 2011). It could be argued that this category overlaps with psychological/emotional abuse. Though these behaviours share a focus on removing control from the older adult, emotional and psychological abuse is more focused on changing control from the older adult to the perpetrator, while in the violation of rights, the focus is on removing from the older adults the power of agency. A difference in focus could even lead to differences in the type of harm that results from such behaviours. We believe that this conceptual difference is important and particularly relevant to analysing these forms of abuse under the scope of some theories. Results from the AVOW study (Ferreira-Alves & Santos, 2011) reinforce the need to consider the denial of rights as a form of abuse. Their results indicate that the denial of rights significantly affects the older adult population (6.4%). Plus, this is a different prevalence than the one found for psychological abuse (23.6%), suggesting some level of independence between these two forms of abuse. Based on these arguments, We believe that denial of rights is a conceptually important form of abuse to consider in research about elder abuse, and it may even help in the theoretical exploration of abuse. 19 As we discussed so far, when specialists discuss abuse, various categories emerge, some more or less agreed upon. These categories may have benefits like helping researchers and practitioners identify abuse, making the dissemination and sensitisation about elder abuse to the general public easier, and giving more structure to teaching and training activities about abuse. There are also downsides to categorising forms of abuse. Two aspects come to mind, and we think they should be discussed. First, some of these types of abuse have been named with an almost judicial tone, for instance, financial exploitation. This nomenclature sometimes denotes an intent of establishing a parallel between abuse typologies and judicial law. However, these typologies should, in our opinion, be considered just as an instrument to understand abuse. The effort of making a parallel between a phenomenological description and a judicially punishable behaviour is probably frustrating and most likely unfruitful. Domestic violence is a good example. Though the term was imported and applied to a judicial setting, in a large number of cases, events that can be phenomenologically labelled as domestic violence legally fall into other categories, such as crimes against physical integrity. A second aspect that we think is a downside of categorising abuse is that it might limit our view and prevent the study of other potentially abusive behaviours that do not fall under the established categories. The typologies of abuse proposed by specialists are an interesting topic of discussion and an acceptable framework for studying the complex operations that lead to abuse. It is, however, noteworthy that these categories do not precisely describe the views or experiences of older adults regarding abuse. Results from Taylor and collaborators' (2014) qualitative study with focus groups indicate that older adults conceptualise abuse in two major categories: the first category encompasses what can be considered as societal abuse, including the notion of respect and the qualities that confer individuality, such as agency and self-awareness; the second category encompasses what happens on an individual level, and includes the emotional cost abuse, the vulnerability of the older adult, the intention of the perpetrator and familial and relational duties. Older adults' conceptions of elder abuse on an individual level are similar to those proposed by the specialists, encompassing physical, psychological, verbal, financial abuse, and neglect. In Taylor and colleagues' (2014) work, sexual abuse was only elicited if prompted, which is congruent with it being the least perceived and acknowledged and the least prevalent form of abuse. But the older adults' conception of elder abuse as societal abuse is an interesting result that differs from the specialists' opinions. This conception links the field of elder abuse very clearly with other concepts such as ageism and human rights, thus justifying more expressively the inclusion of denial of rights as a form of abuse in further studies. Plus, there might be other behaviours older adults consider abusive and are not included in these categorisations. Take, for example, the results of Rocha (2017) into account. By interviewing 20 older adults, six themes emerged, each portraying a class of abusive behaviour against older adults. They were: 1) exclusion – events when an older adult wanted to participate or be taken into account but was excluded; 2) breach of trust – situations when expectations about close ones are broken; 3) Aggressiveness – episodes that result in intentional physical and/or psychological harm; 4) Disrespect – episodes portrayed by younger people that seem to consider older people lesser people; 5) Depersonalisation – episodes portrayed by health or care professionals where adequate care is absent; and 6) Financial restriction – episodes related with limiting access to the older adult's own financial resources. Of these themes, aggressiveness and financial restriction can be considered equivalent to physical, emotional, and financial abuse definitions put out by specialists, while disrespect is more in line with the societal abuse found by Taylor and collaborators (2014). However, exclusion, breach of trust, and depersonalisation are interesting findings that add more knowledge to the already known forms of abuse. It is clear to us that elder abuse cannot be restricted to a few selected forms or behaviours considered abusive by specialists. Though research cannot include every new aspect found about the abuse phenomenon, we think it is important to keep in mind that specialists’ typologies of abuse, though necessary, pose a limitation to understanding elder abuse fully. Conceptually, elder abuse and its forms are not entirely consensual. But, perhaps the variety and doubts raised by these definitions can reflect another problem: the lack of well-grounded explanations for abuse. Not being fully able to define abuse can be a side effect of not being able to explain how and why it happens. Why Does Abuse in Older Age Happen? Research on elder abuse has been focused on estimating prevalences, developing and validating measures and figuring out risk factors. These topics are highly relevant for practitioners but are centred on the phenomenon's description, while its comprehension is left behind. Understanding the “inner workings” of elder abuse is fundamental to progress in this field. The fundamental question is: why does it happen? – that is, what are the underlying mechanics of abuse?; is there any system that allows the prediction of abuse? To approach these questions is necessary to look into the theoretical explanations for elder abuse. However, research in this field has little concern about theoretical development. Nevertheless, the specialists have agreed that theoretical development is one of the most urgent gaps to fill in order to enhance everything else (Stahl, 2015). 21 In the following sections, we will address the theoretical explanations of elder abuse. We will start by discussing in more detail why theory is important in the field of elder abuse and then move to illustrate some of the theories. The Importance of Studying Theoretical Explanations for Elder Abuse The field of elder abuse is not primarily a research field but an applied area. Developing knowledge just for the sake of knowledge is not enough, and practical implications are demanded from whoever approaches this field. More exploration of theoretical explanations for elder abuse is necessary for the natural movement of knowledge from research to policy and practice to be smooth (Moore, 2020; Roberto & Teaster, 2017). These explanations are the backbone for predictions over why and how abuse happens and what consequences can be expected. By providing such explanations, theory gives a guiding frame to interpret and give meaning to empirical data. Consequentially, researchers', professionals', educators', and policymakers' choices are influenced by their theoretical knowledge (Roberto & Teaster, 2017). Relying on limited theoretical knowledge that results from the scarcity of studies testing theoretical frameworks leaves many researchers, professionals, and policymakers to rely on limited information and, sometimes, on their beliefs on the validity of each theory. Elder abuse, being a field that only recently came to the scientific community's interest, has adopted a strategy of theoretical development common in many other blooming fields. That approach consists of borrowing theoretical explanations from other fields and applying them to elder abuse (Moore, 2020; Roberto & Teaster, 2017). Some theoretical models used to explain elder abuse were adapted from child abuse or intimate partner violence. Most of these theories are used to explain how specific processes lead to violent behaviours directed at older adults. Exploring several works that mention theories of abuse (Abolfathi Momtaz et al., 2013; Burnight & Mosqueda, 2011; Mathew & Nair, 2017; Moore, 2019; Pillemer & Wolf, 1986; Wilber & McNeilly, 2001), an enormous list of theoretical frameworks can be compiled: caregiver stress theory; social learning theory; bidirectional theory; psychopathology of the caregiver; social exchange theory; dyadic discord theory; power and control/feminist approach; ecological model; socio-cultural model; political-economic theory; role accumulation theory; stratification theory; and symbolic interactionism. There are probably, somewhere, more theoretical perspectives listed. Not all of these frameworks typically referred to as explanations for elder abuse can predict if and when abuse occurs. However, each of the mentioned theoretical frameworks has its merits and uses. The title of this thesis makes it obvious on which theory we focus. However, a brief overview of the more 22 influential theories is essential to understand why we chose Social Exchange Theory. In the following sections, we will briefly describe the theories that traditionally have been more explored in the literature. Later, in Chapter II, we will get into more detail and review the literature supporting these and other theories of elder abuse. Caregiver Stress Theory The most divulged theory of abuse, and probably one of the more often criticised, is the caregiver stress theory (Bergeron, 2001; Pillemer & Wolf, 1986). According to this theory, abuse occurs in caregiving relationships when the caregiver is overburdened and becomes unable to care for the older adult appropriately. This explanation assumes that caregiving is an inductor of stress and that there is an interaction between the personal factors of the caregiver (e.g., coping skills; caregiving skills), carerecipient factors (e.g., high dependency; low health) and environmental factors (e.g., economic status; lack of support), resulting in feelings of burden (Mathew & Nair, 2017). In turn, an overburdened caregiver would provide care with inferior quality and unleash his/her frustrations and anguishes on the carereceiver in an abusive way. This perspective was criticised for several reasons, among them the argument that non-abusive caregivers also experience stress and that anxiety is more often a response to stress than violence (Brandl & Raymond, 2012). Psychopathology of the Caregiver Psychopathology of the caregiver is also a common explanation for elder abuse. This explanation attributes the use of violence in caregiving relationships as a consequence of the caregiver's abnormal mental health state. The clinical condition of the caregiver is classified in a diagnostic system of possible dysfunctions of human behaviour. The main hypothesis of this theory is that mental health problems hinder the ability to perform adequate care and might even induce violent responses (Fulmer et al., 2004). This explanation arises from the literature that finds perpetrator characteristics to be the more frequently associated with abuse (Kleinschmidt, 1997), mainly behaviour problems and mental/emotional problems (Reis & Nahmiash, 1998). Substance abuse and dependence also appear frequently associated with abuse (Chen & Dong, 2017). Despite caregiver psychopathology being a theoretical explanation, it is not particularly insightful in its broad sense, and that is one of the criticisms that can be pointed out. The explanation is based on the co-occurrence of two phenomena (elder abuse and mental health problems), and data generally supports this association (Conrad et al., 2019; Wiglesworth et al., 2010). However, there are studies showing that mental health might just be another piece of the puzzle and not the direct 23 precipitant of abusive situations (MacNeil et al., 2010; Williamson et al., 2001). It can be argued that this theory might confuse correlation with causation since it is unclear what had the first onset – psychopathology or abuse. The Feminist Approach/Power and Control Theory If we want to account for influence on policy and societal awareness of elder abuse, the power, and control theory, more commonly known as feminist theory, is unavoidable. Again, this theory was not designed for elder abuse but is frequently used as a framework for it. The explanation provided by the feminist approach focus on spousal elder abuse (Abolfathi Momtaz et al., 2013). According to this approach, abuse is perpetrated by men against older women within a social and cultural context that attributes more social and financial power to men. Violence is, in this approach, a consequence of men having more power and regarding women as property (Abolfathi Momtaz et al., 2013). Several points make this approach criticizable as an explanation for elder abuse. First, this approach does not explain male victims of elder abuse. A recent meta-analysis found no gender differences in elder abuse victims (Yon et al., 2017). Plus, this approach focuses on spousal elder abuse perpetrated by men. Studies find a complex variability of perpetrators of elder abuse, who are frequently women, depending on the level of risk in the situation and the type of abuse (Deliema et al., 2018; Jackson, 2014; Santos et al., 2019). In fact, because of these limitations, some scholars have proposed a different explanation, the dyadic discord theory, that instead of relying on gender and social/cultural attributions to gender roles, relies on the relationship dynamics, more specifically in the history of relational satisfaction or conflict as the cause for abuse (Burnight & Mosqueda, 2011). Obstacles to Theoretical Development in Elder Abuse As argued before, the development of theories about elder abuse has been lacking. Several factors can hinder the effort to develop and test theories that explain elder abuse. Next, we will discuss the obstacles that we find more worrying. Lack of Immediate Practical Implications. The field of elder abuse is generally concerned with practical applications. The absence of immediate practical implications derived from the theoretical exploration of elder abuse is one aspect that usually discourages the focus on this subject (Roberto & Teaster, 2017). Studies about prevalences, screening instruments and risk factors are usually more interesting for practitioners. However, theories pose the base for organising knowledge that will eventually have practical implications. 24 Lack of Interconnectedness Between Theories. The theories mentioned in the previous section have a very narrow scope, focusing on very concrete processes. That is probably why some authors consider that each theory should not be used blindly without considering elements of the others (Abolfathi Momtaz et al., 2013; Burnight & Mosqueda, 2011). The insufficient theoretical depth of each theory, when used separately, is a possible explanation for the failures in developing interventions (Burnes et al., 2020). Nevertheless, the lack of theoretical research, the variety of theoretical positions, or their possible interconnectivity might hinder the further development of theories that explain abuse. Explaining vs Blaming. Sometimes, criticising theoretical positions, whilst forgetting the function of a theory, can be counterproductive. One good example is a frequent criticism made to caregiver stress theory. Disturbingly, this criticism can be applied to pretty much any other theory. Brandl and Raymond (2012) state (and have been supported by others) that the proposition made by caregiver stress theory can be used to blame the victims and minimize the offender's accountability. Any other theory that provides explanatory mechanisms can be used to such ends. However, it is not the purpose of a theory to pose moral or criminal judgments over anything; the purpose of a theory is merely to provide an explanation based on objective observations. We think these judgments over theoretical explanations are misguided and hinder the theoretical development and, consequently, the progress that could be achieved with a way to predict elder abuse. Not One Abuse, But Many. Some recent works have focused on the development of new theories based on collected data that try to explain different mechanisms for different forms of abuse (e.g., Jackson & Hafemeister, 2013). The subjacent idea is that each form of abuse is a construct on its own, and thus abuse cannot be seen as a monolithic phenomenon (Jackson & Hafemeister, 2013). This idea is interesting but also has its downsides. We find two compelling reasons for not creating theories for each form of abuse. First, though scholars such as Jackson and Hafemeister (2012) consider mixed forms of abuse in their works, the range of possibilities of overlap between types of abuse is so vast and phenomenologically different that it would probably demand a number of theories as vast as the number of possible abusive acts. Second, and the one we find more compelling, the types of abuse we know of and are subjacent to the current definitions of abuse are categorisations created by specialists and might be a poor fit for the older adults’ experience of abuse. We can look at studies that ask for older adults' perceptions of abuse to support this claim. The categories that emerge are quite different from the ones proposed by specialists. They can include, for example, exclusion, trust breach, aggressiveness, disrespect, depersonalisation, financial restriction (Rocha, 2017), societal abuse and individual abuse (Taylor et al., 2014) and violation of family obligations and loyalties (Chang & Moon, 1997). These 25 differences between what older adults and specialists consider abuse could limit theories built upon abuse typologies. Social Exchange Theory – an alternative explanation Two of the obstacles to theory development previously discussed are easier to tackle: the variety of representations of abuse and the interconnectedness between the micro-processes of each theory. Perhaps to deal with these issues, we do not need a new theory. Perhaps we need to reinterpret an old one, preferably one that is not focused on micro-processes of abuse but on relational macro processes, therefore accounting for the multiplicity of abusive interactions, without being dependent on typologies. Social exchange theory has the potential to fulfil that requirement. Social exchange theory was not designed to explain violence but rather to work as a frame for analysing all forms of human interaction (Blau, 1964; Emerson, 1976; Homans, 1961). In this way, the processes described by the other theories of abuse can also be described as social exchanges. Social exchange theory classifies what can be described as a metatheory, a theory that allows for the description and inclusion of multiple theories into the same framework. The possibility of coupling multiple theoretical stances allows social exchange theory to integrate the differences found in theories that better explain one form of abuse over another. In the elder abuse literature, social exchange theory is mentioned frequently, but it is almost always oversimplified. Social exchange theory is a fairly complex theory with many underlying concepts, and simplification can result from their misinterpretation. As understanding its bases is essential to formulate an operationalisation capable of explaining elder abuse, we will dedicate the next section to exploring the basic principles of social exchange theory in detail. Equipped with that set of basic principles, we will move to how some authors have conceptualised the impact of ageing on social exchanges, and only after that will we apply social exchange to elder abuse. Basic principles of social exchange theory Social exchange theory’s main influences come from sociology and psychology. It is derived from the philosophical perspective of utilitarianism and is clearly influenced by B. F. Skinner's operant conditioning (Cook et al., 2013). The influences from economic theories are present in social exchange theory, and some authors point to Adam Smith, the father of modern economics, as the historical precedent of social exchange theory (Nord, 1973). Many authors contributed to its development, mainly John W. Thibaut and Harold H. Kelley, George C. Homans, Peter M. Blau, Richard M. Emerson, and 32 the more powerful partner in the exchange might be “forced” to conduct an exchange that is not advantageous because there are consequences imposed by a third party (laws, society, family, just to name a few examples). In that case, should it not also be considered that, under certain circumstances, the more powerful partner might also seek balance in the exchange? In the more prominent works, that possibility has not been considered in the social exchange literature. However, by the basic principles of social exchange and considering that exchanges, even dyadic ones, are conducted within an environment full of variables, that possibility must be admitted. Let us consider the central axiom of social exchange theory (maximize rewards and diminish costs). A powerful partner might seek to balance an exchange from which he or she cannot withdraw by increasing the cost of the exchange for the other partner. Plus, as the value of resources is subjective, each partner might have a different perception about the balance of the exchange. With these arguments in mind, we can expand on the view of Emerson (1976) and consider that it is possible that both he who feels dependent and he who feels more powerful might act in order to seek balance in the exchange relationship. This expansion of Emerson’s idea of balancing operations is only possible due to the subjective nature of the concept of value, which reflects on each partner's perception of fairness. One person can perceive the exchange as unfair, while the other does not, and both can consider the exchange disadvantageous. The subjective nature of the value of the resources is the most severe difficulty of social exchange theory in terms of measurement and testing but allows the theory to be versatile and achieve a level of face validity not easy to find. The Impact of Ageing on Social Exchange Much more can be explored in social exchange theory. We could talk about the divergences between theorists on the acquisition, maintenance and use of power or about the influence of power on social status and vice versa. However, we have covered the core concepts of social exchange, and it is time to move forward. Before we can think about framing elder abuse in a social exchange paradigm, we need to consider how ageing may influence our needs and exchanges with others. We have already discussed the issue of biological, psychological and social changes in the ageing process. Now is the time to discuss how these changes may influence our exchanges with others. The possibility for differences in social exchanges involving older actors has been considered by Dowd (1975), who has theorised about how older adults would fare in social exchange, giving a bigger incidence to macro social exchanges involving ageing and power. Dowd depicts the ageing process to be accompanied by a decrease in power and resources (Dowd, 1975). The argument is that as age 33 progresses, social expectations and institutions are set to limit the value of the resources owned by older adults. Retirement, for example, is depicted as depriving ageing adults of resources and power in their relations by limiting their economic resources and labour exchanges, putting the older adult always in a position of power inferiority at the beginning of an exchange. Adding to this, older adults are under the effect of something Webster and Driskell (1978) referred to as status generalisation, a set of expectations that influence the current interaction and are imported from other interactions with other actors. Assuming that a partner has limited resources from the start forces the actor to prove that he/she is a viable trade partner, lowering his/her initial power in any exchange (Dowd, 1975). This concept from the social exchange has a remarkable resemblance to ageism. Stereotyping under biased generalisations of the characteristics of an age group is halfway to creating power disadvantages for older adults even before an exchange starts. Dowd considers that a major influence on power differences between younger and older adults is related to social and cultural experiences (Dowd, 1975). That is to say, differences in resources and power between younger and older adults result not from ageing itself or biological or cognitive changes but cohort-defining differences in experiences of educational, socioeconomic, familial or occupational nature. Dowd argues that with the onset of the industrial revolution and the subsequent specialisation of knowledge, the old worker has little to exchange with the young worker (Dowd, 1975). Though interesting, Dowd's work is tied to the societal view of older adults and the idea that resources are a product of labour or a career. However, even if retirement can limit resources, other facets of the self can also impact resources by decreasing, maintaining, or even increasing them in old age. Besides an active work life, other factors must be considered to understand how ageing changes resources. The impact of ageing on the ability to produce resources will be influenced by the biological, cognitive, and social changes of the ageing process, how individuals deal with those changes and how they adapt to their new reality. Dowd's work is particularly relevant for several reasons. Mainly, it stresses the importance of the transition between working life to retirement in shaping social exchanges. However, in Dowd’s work, there is also the underlying idea that different ageing experiences and developmental pathways influence resources, needs and power in exchanges. So, what is the influence of the other ageing-related changes in the exchange? There is not much information in that regard, but some things can be hypothesised by studying theoretical frameworks of ageing. 34 Social Exchange Theory and Development in Later Adulthood With the basic principles of social exchange in mind, we can look at some theories of adult development and find some common points. In the following paragraphs, we will explore a little bit how some theories about ageing can interact with social exchange theory. Hopefully, this discussion can help understand how normal ageing can change social exchanges, integrating social exchange through a developmental lens. We think that the ageing process can alter exchanges meaningfully in two ways. The first one is by changing the objective of the exchange, the reason “why” we would prefer some exchanges over others. We can classify exchanges conducted on an everyday basis in two categories: 1) exchanges that are instrumental for our survival (obtaining food, clothing, safety) and 2) exchanges that are a means to our promotion of well-being and fulfilment of objectives, and self-actualization. Exchanges conducted to promote well-being or fulfil objectives probably have some parallels with adult development theories. Erikson’s theory of psychosocial development conceptualizes a set of developmental stages across the lifespan, each stage with a developmental task (Erikson, 1963; Erikson & Erikson, 1998). Completing these tasks guides objectives in the various stages of development. Therefore, it can be understood that some exchanges are carried on with the objective of completing different developmental tasks. For example, some interactions between young adults might be conducted to find a partner, thus tackling the intimacy vs isolation stage. Likewise, an older adult telling a story about his or her life can be a reminiscence experience that will contribute to the challenge of integrity vs despair (Erikson & Erikson, 1998). Also, we may choose to conduct some exchanges simply because of their emotional outcome. In this case, we can establish a parallel with the Socio-emotional selectivity theory. This theory predicts a change of focus in advanced age from knowledge-oriented goals to emotion-oriented goals (Carstensen, 1991). This means that the prefered exchange will be one that suppresses an emotional need and not a more cognitive-oriented need. Plus, from this premise, we can predict that the goals of the exchange can differ in intergenerational relationships (Carstensen, 1991, 2006). Different goals in exchanges can result in some tension and eventually in conflict. Research indicates that, in old age, there is a reduction in social contact in general. However, socio-emotional selectivity predicts that relationships in old age tend to focus on meaningful familiar and secure connections (Coleman & O’Hanlon, 2017). From the social exchange point of view, it could result in fewer partners to exchange with. A reduction in social partners has a major implication for exchanges. Dependency on a partner is directly conditional on the availability of other partners. A reduced or limited 35 social network reduces the possibility of finding alternative exchange partners, resulting in dependence and low power on the existing relationships (Emerson, 1962). The second way ageing can interfere with exchanges is by changing the “how” of the exchange, how we conduct exchanges, the available resources, and how we adapt to resource limitations. As we explored at the beginning of this text, some functional changes are expected with old age, which can impact everyday life and, consequently, our exchanges. The theory of selective optimization with compensation explored earlier offers an explanation of mechanisms to adapt to these changes. According to this theory, adaptative change implies the use of three strategies: selection, optimization and compensation (P. B. Baltes, 1997). The application of these strategies can change the shape of the resources put in exchange and, therefore, condition exchanges. Plus, one possible way to suppress needs is simply by getting help, which can be viewed as a compensation strategy. Getting help implies conducting exchanges with others to obtain help. Therefore, getting help as a form of compensation can increase the number of exchanges and even lead to dependency (Homans, 1961). Summing up, social exchange theory has quite a few connections with adult development theories. That does not necessarily mean that social exchange is a developmental theory, but it certainly means that it explains human interactions within their developmental context. Using social exchange theory to explain elder abuse means that abuse is understood within its developmental context. Accounting for development in the explanation of abuse is, in our opinion, a huge boon of social exchange theory. As a metatheory, the social exchange theory applied to elder abuse does not hide developmental processes; it allows the visibility of each actor's developmental needs and goals and, in that sense, admits the pursuit of a developmental view of abuse. Applying Social Exchange Theory to Elder Abuse So far, we have explored the basic principles of social exchange and their connection to ageing and development. We have also explored elder abuse from its conceptual standpoint, discussing the definition of abuse and the definitions of each form of abuse. It is now time to cross these two points and formulate a possible articulation and application of the basic principles of social exchange theory to explain elder abuse. When we typically read about social exchange theory and elder abuse, dependency and limitations in the older adult’s everyday life are commonly the central pieces of the explanation (Abolfathi Momtaz et al., 2013; Wilber & McNeilly, 2001). Few authors consider at least some of the principles of social exchange when explaining elder abuse (one example is Mathew & Nair, 2017). Without a detailed 36 application of the social exchange principles to elder abuse, any explanation will be superficial and potentially ignore the explanatory power of a complex theory such as social exchange theory. In the following paragraphs, we will formulate concrete explanations for elder abuse based on social exchange principles. When considering an explanation for elder abuse based on the social exchange theory, it is helpful to first think about what assumptions that approach would have. Based on the principles of social exchange theory, we can formulate five assumptions: 1. Elder abuse is an exchange; 2. Abusive exchanges are better understood in the context of previous exchanges; 3. Abusive exchanges imply power inequalities; 4. Abusive exchanges are a response by the more powerful actor to a perceived broken distributive justice; 5. By using an abusive exchange, the more powerful actor will try to maximize rewards, decrease costs or reduce the gap between the perception of his/her profit and his/her perception of his/her partner’s profit. Let us delve into more detail about these assumptions. Looking at elder abuse from a social exchange perspective means that the relational nature of abuse is central (assumption 1). Abuse can only be read as a social exchange where the exchanged resource is abusive behaviour. As discussed before, when choosing resources, the actors consider if those resources provided successful exchanges in the past. When framing elder abuse into a social exchange lens, we assume that abusive behaviour was not the first choice of resource to start a relationship. Consequently, we assume that abuse emerges in relationships gradually, meaning that other exchanges were conducted before the abusive exchange took place (assumption 2). There is some evidence supporting this assumption. Research shows that caregivers who commit abuse have a worse relationship with the care recipients than the caregiver who does not commit abuse (Compton et al., 1997). Plus, elder abuse committed by caregivers is positively correlated with the perception of fewer rewards from the past relationship with the older adult (Cooper et al., 2010). The appraisal of past exchanges serves as a base for the expectations of future exchanges. As such, factors that contribute to increased dependency, such as the societal and labour factors identified by Dowd (1975) or other factors that contribute to dependency, also contribute to creating power inequalities. The emergence of abusive exchanges is tied to power inequalities (assumption 3). Exchanges conducted in relationships where power is equally distributed to the partners are mutually satisfying; they 37 cannot be abusive. On the other hand, in relationships with power imbalances, at least one of the actors is unsatisfied. This assumption is supported by research that indicates that relational quality is compromised in relationships where there is abuse (Cooper et al., 2010; Jackson & Hafemeister, 2011). Power inequalities indicate that one actor is more powerful than the other, which is the same as saying that one actor is dependent on the other. Differences in power or dependency result from one actor perceiving the exchanges as unfair (broken distributive justice). As described in the fifth proposition of the social exchange theory (Homans, 1961), actors who perceive exchanges as unfair tend to respond less rationally. This interpretation of social exchange expects abuse to emerge in this context (assumption 4). Supposing abusive behaviour is a response to an exchange history where one actor (the abuser) has the perception that his/her profit in that relationship is smaller than the profit of the other actor, as proposed in assumption 4. In that case, abusive behaviour is used as a strategy to decrease that gap (assumption 5). This means that abusive behaviour is used to increase rewards, decrease costs or decrease the profit of the other actor to make both actors' profits more comparable in the eyes of the abuser. This logic is by no means an excuse for the use of abusive behaviour; as discussed in the section about the basic principles of social exchange theory, other non-abusive strategies can be employed to restore balance in relationships. This point begs the question: if there are non-abusive alternatives to restore balance, why do some caregivers use abusive strategies instead of non-abusive strategies? Although this distinction was not the point of this work, we could venture to hypothesize that caregivers who use abusive strategies to restore balance probably lack the resources, knowledge or insight to choose non-abusive strategies. In a way, using abusive strategies shows an inability to find alternative strategies, stressing the idea that the caregiver is not necessarily someone to blame but someone who also needs help. Types of Abuse on a Social Exchange View A consequence of these assumptions, particularly two, four and five, is the variability of possible expressions of abusive behaviour. Suppose each abusive behaviour is the last link of a chain of exchanges and performed as a result of that history of exchanges. In that case, we should expect it to take different forms depending on that history. However, despite those many forms, we can cluster exchanges by similarity, for example, the similarity of the outcome. In that case, we can hypothesize that certain exchange chains can lead to similar outcomes. If these outcomes are the types of abuse, we can think of different exchange-based mechanisms to explain each form of abuse. This is one of the points that make 38 social exchange theory appealing. The possibility for different exchange-based mechanisms for the different types of abuse is aligned both with the different behavioural manifestations of abuse and with the opinion of some experts in theories of abuse (Jackson & Hafemeister, 2016), who defends that each type of abuse warrants its own explanation. So, what could these exchange-based mechanisms look like? Well, considering assumption five, these mechanisms could try to 1) increase rewards for the abuser, 2) increase the cost of exchange for the older adult or 3) reduce the cost of exchange for the abuser. One way to increase rewards that can be classified as abusive is to take monetary compensation forcefully by seizing money or property from the older adult against his or her wishes. This kind of abusive behaviour can be classified as financial exploitation (National Center on Elder Abuse, 2015). In other situations, the actor might not be able to find strategies to increase rewards and might try to increase the cost of the exchange for the older adult in what we can classify as a lose-lose scenario. Abusive behaviours that configure physical and emotional abuse could be used to inflict pain or distress, thus increasing the cost of exchanges for the older adult. One way for the actor who commits abuse to reduce costs could be by withdrawing from providing care or providing insufficient care. This denial in providing care can be classified as neglect. These individual mechanisms do not exclude situations where more than one form of abuse is present. As it is known, older adults who experience abuse frequently experience more than one form of abuse. These mechanisms can be used concomitantly, inflicting more than one form of abuse. For example, taking property can be classified as financial exploitation. However, this behaviour can also be used in order to humiliate the older adult, thus classifying it as psychological abuse. This same behaviour can be conceptually understood as two related but different exchanges: one where the resource was “take the property” and the other where the resource was “humiliate”. Thus, this conceptualization includes the possibility of the same behaviour being abusive in more than one way. Using the Principles of Social Exchange Theory to Predict Elder Abuse From the theoretical premises explored in the previous section, we can say that any factor contributing to an increased risk of unbalanced exchanges can potentially lead to abusive exchanges. Therefore, two main issues can promote unbalanced exchanges: 1) lack of access to resources valued by the other and 2) high dependency (or low power) on the other. These two factors are essential contributors to assessing exchanges as not fulfiling the distributive justice principle. Understanding these two factors allows us to make some predictions about elder abuse. In the following sections, We will explore the role of resources in predicting elder abuse, the role of power/dependency and how the two 39 may come together, formulating the core of the predictions that become the central hypothesis for this thesis. The Role of Resources Difficulties accessing resources make it harder to reciprocate a received resource. Limitations in producing resources to exchange limit the ability to have balanced exchanges and, consequently, limited resources can be connected to the emergence of abusive exchanges. However, the wide variety of resources creates difficulty in assessing them and relating them to abuse. Probably the easier resources to measure are financial resources. Some studies relate financial resources to elder abuse, showing that older adults report abuse more frequently when they are unemployed, have low income or have low socioeconomic status (Abdel Rahman & El Gaafary, 2012; Acierno et al., 2010; Litwin & Zoabi, 2004; Naughton et al., 2012). These results are congruent with this theorization of abuse. However, most of our daily exchanges are not economic but based on behaviour, which creates a problem: how do we assess behavioural resources? We do not know how to answer this question, but we can propose an alternative route to assess behavioural resources. Instead of looking directly at resources, we can look for variables that are important for producing those resources. Let us think of a conversation as an example of an exchange where both actors may be trading information, experiences or simply pleasantries. To sustain such an exchange and contribute to it in full, those persons involved need to have access to particular cognitive abilities. Telling a story requires at least memory, verbal fluency and executive function. Good performance with these skills makes it more likely to participate in such exchanges successfully. As assessing resources directly could be troublesome due to their vast variability in behavioural representations, we can, alternatively, assess the necessary skills to create those resources. The idea that certain abilities and skills influence our behaviour, and therefore the resources used in exchanges, has some support. Continuing with the example of cognition, the results from Conner and collaborators (2011) indicate that cognitive impairment is a predictor of elder abuse mediated by behavioural problems. Thus, it seems that assessing variables that may change the form and content of the resources may be a way to approach the role of resources in a social exchange perspective of elder abuse. In assessing skills and abilities, we gain insight into what resources are available to exchange, allowing us to contour the issue raised by the variability of behavioural representations of resources. We can then test the social exchange explanation to elder abuse by testing if poor performance with these skills increases the chance of abusive exchanges. 40 Research on elder abuse does not frequently include variables that fit the reasoning above, except for cognitive status or cognitive impairment, which are included very frequently. However, the results obtained are sometimes contradictory. Many studies find a positive association between poorer cognitive functioning and elder abuse (e.g., Cooper et al., 2006; Lachs et al., 1997; Serra et al., 2018), but many others find no relationship between the two (e.g., Leung et al., 2017; Luo & Waite, 2011; Vida et al., 2002). Nevertheless, some principles of social exchange theory might help explain these contradictory results. As previously discussed, Social exchange may be used to think of different pathways that lead to different forms of abuse. In that case, it may make sense that some forms of abuse might be related to cognitive functioning while others are not. The cited studies only focus on abuse as a whole and not on its types. When looking at specific types of abuse, evidence suggests a positive association between poor cognitive function and financial exploitation (Garre-Olmo et al., 2009) and psychological abuse (Wang, 2006). Therefore, cognitive skills might be more important predictors for some forms of abuse than others, which supports the theorized explanation based on social exchange principles. However, we can go even further because we hypothesize that different cognitive structures might be necessary to perform different resources; thus, different cognitive structures might be differently associated with the different forms of abuse. Nevertheless, research relating cognition with elder abuse rarely assesses cognitive structures independently of each other, depending instead on measures designed to screen for cognitive impairment that rely on a single and unspecific score for cognitive performance. Dong and collaborators (2011) conducted one of the few studies that can help us understand the relationship between different cognitive structures and the types of abuse. In this study, the authors explored relations between episodic memory and perceptual speed with physical abuse, emotional abuse, neglect and financial exploitation. The results indicate that episodic memory is a good predictor of neglect and financial exploitation, not physical and emotional abuse. At the same time, perceptual speed is a good predictor of emotional abuse, neglect and financial exploitation, but not for physical abuse. These results reiterate that neither cognition nor abuse can be treated as monolithic structures. Integrating these results within the social exchange framework supports the idea that different cognitive structures are behind different resources; therefore, they can be used to predict different forms of abuse when assessed independently. However, there is insufficient research relating specific cognitive structures to elder abuse. To more accurately include cognition in an explanation of elder abuse based on social exchange is necessary to explore a broader set of cognitive structures and determine which cognitive structures are relevant predictors of the different types of abuse. 41 However, it is not only cognition that shapes behaviour and, consequentially, resources. Looking only at cognition gives just a partial understanding of resources. It is necessary to study other domains that have the potential to determine the choice of one behaviour over another and, therefore, affect the selection of resources. Research that includes such kinds of variables is scarce. One example of one variable that would fit this description is personality. In support of this view, research shows a positive association between older adults’ neuroticism and overall abuse (Li et al., 2020). The relationship between personality and abuse also changes depending on the form of abuse. Higher neuroticism is associated with an increased risk of psychological abuse, financial exploitation and caregiver neglect (Li et al., 2020). Though consciousness is negatively associated with overall abuse, high consciousness increases the risk of financial exploitation (Li et al., 2020). As exchanges are like two-way streets, determinants of resources for both older adults and caregivers are important to understand abuse. While the older adult's resources' determinants indicate older adult-related risk factors, determinants of the caregiver's resources indicate caregiver-related risk factors. Continuing with the example of personality to illustrate this point, high neuroticism in caregivers is associated with physical and psychological abuse (Fang et al., 2021). However, the increased risk posed by caregiver neuroticism disappears when the burden is low (Fang et al., 2021). Although Fang and collaborators (2021) found an association between caregiver neuroticism and neglect, that relationship was not affected by burden. In sum, determinants of resources of both older adults and their caregivers play an important role in the prediction of elder abuse. However, each resource seems to be tied to certain forms of abuse, suggesting that abuse needs to be understood by its type and not necessarily as a whole. Many other variables can be studied to determine the role of resources in predicting elder abuse. Each contribution, even if small, can give important elements to add more detail to an explanation for elder abuse based on the principles of social exchange theory. However, it is not only determinants of resources that are important to understand elder abuse. As indicated in Fang and collaborators' (2021) study, other variables, such as burden, may affect the relationship between resources and abuse. We can conceptualize these variables as interfering with the power-dependence dynamics. The Role of Power/Dependence The power-dependency dynamics are important factors directly associated with evaluating exchanges as unbalanced. Power and dependency are closely related to resources. Difficulties in producing resources are strongly associated with increased needs. The higher the needs, the more likely one is to become dependent on another. So, how to approach power/dependence? One way is to focus 48 References Abdel Rahman, T. T., & El Gaafary, M. M. (2012). Elder mistreatment in a rural area in Egypt. Geriatrics and Gerontology International , 12 (3), 532–537. https://doi.org/10.1111/j.14470594.2011.00780.x Abolfathi Momtaz, Y., Hamid, T. A., & Ibrahim, R. (2013). Theories and measures of elder abuse. Psychogeriatrics , 13 (3), 182–188. https://doi.org/10.1111/psyg.12009 Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). 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In five different works (Abolfathi Momtaz et al., 2013; Burnight & Mosqueda, 2011; Mathew & Nair, 2017; Pillemer & Wolf, 1986; Wilber & McNeilly, 2001), we counted a total of 13 theories: caregiver stress theory; social learning theory; bidirectional theory; psychopathology of the caregiver; social exchange theory; dyadic discord theory; power and control/feminist approach; ecological model; sociocultural model; political-economic theory; role accumulation theory; stratification theory; symbolic interactionism. This list of theories was the starting point for the current review. Political-economic theory is very rarely cited and can be considered a specific case of social exchange theory. Role accumulation theory and stratification theory are also rarely cited and are both specific cases of caregiver stress theory. When addressing theoretical approaches, it is fundamental to differentiate between theories and models. A theory shapes empirical fact with logic and reasoning into an explanatory framework, allowing predictions based on the formulation of a hypothesis for testing. A model, however, is a representation of a phenomenon (often distorted) to enhance conceptual understanding (Burnight & Mosqueda, 2011). The main difference between model and theory is that theories focus on establishing causal prediction, while models focus on framing descriptions of phenomenons. Models are helpful in case analysis but have low power establishing predictions or hypothesis development. The ecological model is a good example; it is a powerful tool to categorise risk factors and organise cases (check Schiamberg et al., 2011, for an application of the ecological model). However, it has limitations in providing a processual explanation for how abuse happens. For these reasons, models will not be included in this review, excluding the ecological model, sociocultural model and symbolic interactionism theory. The power and control/feminist approach will also not be included in this review. A meta-analysis by Yon and collaborators (2017) showed no gender differences in overall elder abuse, indicating that the mechanics behind elder abuse might be more complicated than just gender roles and expectations, which supports previous findings in the field of intimate partner violence (Archer, 2000). Additionally, dyadic discord theory emerged as a response to these perspectives, offering an expanded explanation of violence, accounting for these data. In summary, we focus on theories that propose a causal mechanism for the prediction of elder abuse and, in this sense, have important repercussions for practical purposes, such as risk assessment and prevention. We will focus on six theories in this systematic review: caregiver stress theory, social exchange theory, social learning theory, bidirectional theory, dyadic discord theory, and the psychopathology of the 65 caregiver. These theories have been pointed out as the best bets to explain elder abuse theoretically (Abolfathi Momtaz et al., 2013; Burnight & Mosqueda, 2011; Mathew & Nair, 2017; Wilber & McNeilly, 2001), but they are not mutually exclusive. Sometimes, their predictions are entangled, proving it difficult to support only one theory. We will briefly describe each one and their main predictions. Caregiver Stress Theory Caregiver stress theory, sometimes addressed as situational stress theory, posits that elder abuse occurs when a stressed/overburdened caregiver unleashes his/her frustrations on the care recipient (Bergeron, 2001; Pillemer & Wolf, 1986). The central premise of this theory is that caregiving is a stressful situation. Sometimes it can be. Stress emerges either from personal factors – such as inadequate coping skills, multiple roles in the family, health problems, lack of caregiving skills; care-recipient factors—such as high levels of dependency, poor health, decreased mental capabilities; or environmental factors— economic difficulties, lack of support from society-level agencies, and social isolation. These factors combined can make the caregiver feel overburdened and frustrated, unleashing it on the care recipient (Mathew & Nair, 2017). This theory has been controversial for several reasons, but mainly because it can be used as a strategy to blame the victim for the abuse, thus reducing the perpetrator’s accountability (see Brandl & Raymond, 2012, for a detailed discussion). However, this theory provides a clear hypothesis. Caregiver stress theory predicts that a stressful or burdened caregiver is at greater risk of committing abuse than a caregiver with less burden. Therefore, good evidence for this theory would be a straightforward relationship between stress and abuse, or, on a more experimental note, the disappearance of abuse after diminishing the caregiver’s stress on previously abusive relationships. Social Exchange Theory Social exchange theory was developed by very different study areas (sociology, psychology and economics) and is usually analysed superficially. According to this theory, every social interaction is an exchange of material or nonmaterial resources between two partners, where all involved partners will try to maximize profits and reduce costs. When all involved parties perceive a balance between profit and costs, there is a mutually satisfying balanced exchange (Blau, 1964). Elder abuse is not expected in balanced relationships but in unbalanced relationships. If one of the exchange partners has limited resources to trade and has increased needs, he/she will become “dependent” on his/her partner. In turn, this partner will gain more “power” over the relationship and manipulate the exchanges to maximize profit and cut losses. The manipulation of exchanges can take many forms: deny necessary exchanges 66 (neglect); take monetary compensation by force (financial exploitation), or even inflict pain or distress (physical and emotional abuse) as a mechanism to vent emotions, to increase the power gap or to create a “balance” where both traders lose. Someone who lacks resources (material or nonmaterial) and has few exchange partners (no social support system to trade with) might become dependent on this “powerful” partner, perpetuating unfair trades (Fundinho & Ferreira-Alves, 2019). However, the term “resources” is too vague (Blau, 1964, lists some resources such as social acceptance or prestige), and it is easier to look for variables that increase the needs and make it more challenging to produce resources. Therefore, evidence for this theory might include a relationship between abuse and physical or cognitive impairments (that increase needs). Additionally, this theory relies on the availability of trade partners; therefore, variables such as network size or loneliness are also of interest. Social Learning Theory Social learning theory (Bandura, 1978) has been known by many names: intergenerational transmission of violence, transgenerational theory, and the cycle of violence theory. From the literature on child mistreatment, social learning theory proposes that violence is learned through observation and modelled into our behavioural repertoire. Social learning posits that someone who was a victim or was exposed to violence as a child is more likely to learn that violent actions are valid strategies to deal with others, resulting in the use of violence in caregiving relationships, thus continuing the violence cycle (Pillemer & Wolf, 1986). The main prediction from this premise is that abusers are more likely to have experienced abuse in their childhood than non-abusers. However, the definitive evidence would have to come from longitudinal studies, following children who were victims or who witnessed abuse and to see if they become perpetrators when the time comes to assume the role of caregiver to their parents. Bidirectional Theory Bidirectional violence theory arises from the work of Steinmetz (1988), who first noticed that, in some cases, it is difficult to pinpoint a perpetrator and a victim since when abuse occurs, older adults and caregivers are mutually aggressive to one another. This theory states that people raised in environments where violence is used as an interaction strategy or in situations where a caregiver or care receiver feels highly stressed are prone to violent outbursts, to which they are responded with more violence (Steinmetz, 1988). Therefore, the main predictions are that, at some point, older adults and caregivers were both victims and perpetrators. Therefore, the evidence that might support this theory would be reports of mutual violence between caregivers and care receivers. 67 Dyadic Discord Theory Dyadic discord theory was developed in the intimate partner violence literature. When the incidence of intimate partner violence began to be studied in larger, nationally representative samples across multiple sources (courts, shelters, police reports, and hospitals), a new understanding of violence emerged regarding gender, since these large-scale studies indicated that women were as violent as men (Archer, 2000). Dyadic discord builds on this finding and focuses on conflict and discordance in relationships (disregarding the gender variable). According to this theory, conflict and discord emerge in a relationship because of contextual factors (history of family violence) and situational factors (e.g., low satisfaction with the relationship), and this discord might work as the onset for violence (Burnight & Mosqueda, 2011). Dyadic discord and bidirectional theory share a relational focus but differ in the depth of analysis. While bidirectional theory is concerned with mutual aggression between two people, dyadic discord considers the family environment and the elements that precede aggression, such as discord and dissatisfaction in a relationship. This theory predicts that highly conflictual relationships are prone to be associated with violence. Favourable evidence for this theory would be, for example, an association between family conflict and elder abuse. Psychopathology of the Caregiver The psychopathology of the caregiver states that elder abuse emerges because the person assuming the caregiving role is suffering some form of psychopathology that makes him/her unable to provide adequate care or even prone to violence (Fulmer et al., 2004). Substance abuse and depression are the more common mental health issues linked to abuse (Chen & Dong, 2017) but are not the only mental health problems. This theory’s prediction is straightforward – if the caregiver has a mental illness, the odds of committing elder abuse increase. Finding evidence for this theory can be tricky; it is not just a simple case of finding associations between mental illness and elder abuse. It is also necessary that mental illness is present before the caregiving relationship starts; otherwise, the causal link cannot be established. If the onset of the mental illness is after the beginning of the caregiving relationship, the mental illness might be a by-product of the relationship, therefore disproving this theory. Methodology Search Strategy We searched databases (Web of Science, Psychinfo, Scopus, Science-Direct (Elsevier), PubMed, Sage and Ageinfo) for research-based articles written in the English language and published in scientific journals 68 from 1975 to October 2018. We used a combination of the following keywords: “elder abuse”, “mistreatment older adults”, “violence older adults”, and “older adults abuse neglect” , added to some theory-specific keywords. The theory-specific keywords were as follows: caregiver stress theory - “caregiver stress”, “caregiver burden”, “stress”, “coping” ; social exchange theory – “social exchange”, “dependency”, “impairment”, “deficits”, “rewards” ; social learning theory – “learning”, “abused children”, “abused spouse”, “intergenerational” ; bidirectional theory – “caregiver”, “mutual violence”, “violent care receiver” ; dyadic discord theory – “relational conflict”, “relational satisfaction”, “disagreement”; psychopathology of the caregiver – “caregiver mental health”, “caregiver psychopathology” . Inclusion and Exclusion Criteria From applying this search strategy, six massive databases of references, one for each theory, were gathered and managed using Mendeley, a reference manager software. Papers were excluded from these databases by analysing the titles and abstracts and applying the following criteria: a) not about elder abuse; b) not presenting empirical data (the reference list of literature reviews was combed for references that respected the previous criteria and were added to the database). Both quantitative and qualitative studies were accepted. Next, two researchers of elder abuse, experts on the theoretical explanations of abuse, analysed the databases and proceeded to a full-text appreciation to apply the last criteria: c) the paper includes a result that might provide evidence in favour or against the theory. In qualitative studies, results of interest would be themes that describe affirmatively or contradict the hypothesis of each theory, as can be seen later. Disagreements were resolved by the two researchers reaching a consensus. The number of articles resulting from each step can be found in Table 1. Table 1Number of citations retained during paper selection process Caregiver Stress Theory Social Exchange Theory Bidirectional Theory Social Learning Theory Dyadic Discord Theory Psychopathology of the caregiver Total number 2908 6045 2932 4833 5854 3657 Criterion a) 1614 3350 1701 2128 1272 1299 Criterion b) 217 376 351 161 47 118 Criterion c) 32 35 18 10 7 15 Data Extraction Selected articles were analysed independently by the two researchers, summarised by mutual agreement and are organised in a table, which displays the sample size, measurement of elder abuse, 69 variable(s) of interest for the theory, the measurement instrument and main results. The table is available in the supplementary material (Appendix A). The two researchers assessed the extracted results in three areas: conceptual/theoretical quality, methodological quality, and evidence quality. To do so, the researchers used the standardised checklist presented in Table 2, created by the authors, specifically aimed to assess the theoretical focus of each paper objectively. The methodological quality questions were created based on previous systematic reviews in the field of elder abuse. One question, presented below as “Evidence”, was used to classify the results as favourable or contradictory for each theory. A consensus between the researchers resolved disagreements. Table 2 – Checklist for assessment of conceptual/theoretical, methodological, and evidence quality of the selected articles Conceptual/Theoretical Quality (0=No; nc=Not clear; 1=Yes): (1) Was the adopted definition of abuse specified? (2) Is a theoretical framework mentioned? Methodological Quality (0=No; nc=Not clear; 1=Yes): (1) Were the measures used validated for the assessed population? (2) Were participant characteristics identified? Evidence (-1 = evidence against; 0 = contradictory evidence; +1 = evidence in favour): (1) Some results support/disprove the theory? Results A total of 89 studies were selected for final revision. Some studies included variables relevant for more than one theory; hence, they were included in all theories where their data were valuable, giving a total of 117 results to analyse. Regarding the conceptual/theoretical quality assessment of the analysed articles, of the 89 studies, 62 (70%) defined how they understood mistreatment, but only 29 (33%) mentioned mistreatment in a theoretical framework. Regarding methodological quality, 51 (57%) studies used validated measures. Finally, 75 (84%) of the studies presented participant characteristics sufficient enough for replication. 70 Caregiver Stress Theory Thirty-two studies were analysed regarding evidence for the caregiver stress theory. Of these, 25 presented caregiver stress or burden as positively associated with mistreatment, therefore favouring the caregiver stress hypothesis. Four studies showed contradictory evidence by finding an association between caregiver burden and some forms of mistreatment, but not others, for example, finding an association between burden and neglect but not physical or psychological mistreatment (Gainey & Payne, 2006; Orfila et al., 2018). Three studies did not support the caregiver stress hypothesis. Cooper and collaborators (2010) did not find any relationship between caregiver burden, dysfunctional coping and mistreatment. The other two negative results are interesting to analyse since they were intervention studies. One intervention programme could diminish mistreatment but not stress (Hsieh et al., 2009), and another could diminish stress but not mistreatment (Reay & Browne, 2002). These results suggest the influence of other variables on the stress-mistreatment relationship. In line with these findings, two studies suggested that stress might have a mediating role rather than be a direct predictor of mistreatment. For instance, with nurses’ aides, caregiver burden acted as a mediator between work stressors and mistreatment, meaning that exposure to work stressors increases abuse indirectly by increasing the feeling of burden (Shinan-Altman & Cohen, 2009), while with the general population of caregivers, caregiver burden was a mediator for social support and resilience (Serra et al., 2018). These mediation results are fascinating because they show that one of the main predictors of caregiver stress theory (caregiver burden) is not the direct cause of abuse but rather one piece of other causal relationships. Of the total number of articles analysed, 20 focused solely on non-professional caregivers of older adults with some form of impairment (e.g., dementia and physical disabilities). Of these, 16 studies presented positive evidence in favour of the caregiver stress hypothesis. Additionally, six studies focused on professional caregivers (e.g., nursing home employees), and of these, 3 presented favourable evidence towards caregiver stress theory. Of the remainder, three studies focused on victims or older adults signalled adult protective services, and three focused on community-dwelling older adults without disabilities. These characteristics of the sample are important to note. The functional status of older adult participants and the professional vs non-professional status of the caregivers may act as confounding variables. 71 Social Exchange Theory There is no direct way to test social exchange theory; thus, we have explored the evidence for this theory, searching for studies that assessed the resources, needs and factors affecting dependency. Most likely, for this reason, the number of articles collected was 35, higher than the other theories. The first interesting result is the narrow variety of personal resources studied in association with abuse. Physical function/dependency was present in 28 studies, cognitive function/impairment in 18 and social function variables, widespread from social support to isolation and loneliness, were present in 20 studies. Eight studies included other resources, mainly economic, such as income or working status. Regarding the predictions of social exchange theory, 19 studies support the predictions, while 3 find evidence against them. Thirteen studies find contradictory evidence. In these cases, only one form of personal resource was associated with abuse (e.g., Sasaki et al., 2007), or different resources were associated with different forms of abuse (e.g., Orfila et al., 2018). As we were interested in mistreatment in all its forms, these studies were classified as contradictory evidence, but it might not be contradictory after all, considering that different needs warrant different resources; therefore, different needs might lead to different forms of mistreatment. Finally, a few studies pointed out mediating roles for some variables of interest for social exchange. For example, in Conner and collaborators (2011), cognitive impairment does not directly predict susceptibility to abuse, but it is mediated by older adults’ problematic behaviours. Kong and Jeon (2018) found no direct association between physical functionality and emotional mistreatment; however, self-esteem and family assistance mediated that relation. Social support also appears to affect mistreatment, mediated by caregiver burden (Serra et al., 2018). These results suggest that we have limited knowledge of what resources are relevant to predict mistreatment and how they manifest themselves in behavioural terms, which is why finding these mediators is essential. Social Learning Theory Ten studies were analysed for evidence for social learning theory. Of these studies, four presented results in favour of the cycle of violence hypothesis, where experiencing or witnessing violence earlier in life would be a predictor of committing violent acts later in life (Dong et al., 2017; Korbin et al., 2005; Reay & Browne, 2001; Yan & Tang, 2003). Of these, Yan and Tang (2003) did not study mistreatment directly but rather the proclivity to commit it, and they found that participants who experienced violence earlier in life were more likely to find mistreatment to older adults acceptable. One important note is that, except for this last study, the participants in previous studies were always caregivers. However, three studies pointed out that experiencing mistreatment at an earlier age would be a risk factor to experience 72 it again later in life (Grunfeld et al., 1996; McDonald & Thomas, 2013; Stöckl et al., 2012). In these three studies, participants were older adults receiving care. Two of the remaining studies showed contradictory evidence (Jackson & Hafemeister, 2011; Jooyoung Kong & Easton, 2018), where previous violence can be a risk factor for some forms of mistreatment but not for others. Last, the participants in Wuest and collaborators’ (2010) qualitative study added that caregiving a previously abusive parent is an opportunity to make amends. From the collected results, it seems that there is contradictory evidence for social learning theory. Two main patterns emerge, first, those who experience violence are more likely to commit violence, and second, those who have experienced violence are more likely to continue experiencing it. The second pattern is not entirely out of the theoretical principles proposed by social learning because when experiencing/witnessing violence at an earlier age, there is exposure to both aggressors and victims as role models. It would not be theoretically wrong to assume that one can learn how to be both abuser and victim. Bidirectional Theory Eighteen studies were analysed for relevant results regarding bidirectional theory. Of these, only 3 showed no relationship between caregiver mistreatment and care-receiver aggressiveness or violence (Cooper et al., 2010; Heydrich et al., 2012; Phillips et al., 2001). The remainder of the articles supported the hypothesis that violence is mutual, showing associations between aggressiveness and violence of the care receiver and mistreatment by a caregiver. Of these supporting studies, 2 (Özcan et al., 2017; Post et al., 2010) show that when looking into the forms of abuse, different forms of violence can be used in response to different types of mistreatment; for example, neglect of the caregiver is associated with physical abuse by the care receiver (Özcan et al., 2017). Dyadic Discord Theory Of the seven studies whose data could support dyadic discord theory, four focused on relational conflict, finding a positive relationship between conflict and mistreatment (Cohen et al., 2006; Pillemer & Finkelhor, 1989; Reay & Browne, 2001; Shugarman et al., 2003). The three other studies focused on relationship quality, all with consistent data that the poorer the relational quality, the higher the risk of abuse (Compton et al., 1997; Cooper et al., 2010; Jackson & Hafemeister, 2011). Both results are consistent with the predictions of dyadic discord theory, and therefore, all the studies support this theory. Important to highlight are the results of Jackson and Hafemeister (2011), who found inferior relational 73 quality in victims of physical mistreatment compared to victims of financial mistreatment. These results suggest that different types of mistreatment may be related to different levels of relational quality. Psychopathology of the Caregiver Of the 15 analysed studies, one did not find differences in the history of mental health problems, depression or alcohol consumption between caregivers who mistreat and caregivers who do not (Cooney et al., 2006). The remaining studies show a positive relationship between mental health, depression, anxiety, substance use, and mistreatment. However, two results seem of importance. First, two studies found that neglect had no relationship to mental health (Conrad et al., 2019; Leung et al., 2017), while only one showed a relation between anxiety and neglect (Reay & Browne, 2001). These results suggest that neglect might be a form of abuse not directly explained by this theory. Second, two studies suggest that mental health plays a moderating or mediating role between other variables and mistreatment; namely, depression and anxiety moderate the relationship between anger and the risk of mistreatment (MacNeil et al., 2010), and depression partially mediates the relationship between relational rewards and the risk of mistreatment (Williamson & Shaffer, 2001). These results suggest that the caregiver’s mental health might not be the first piece of the puzzle but an important risk factor for mistreatment that should always be considered. Discussion This systematic review analysed 89 research papers searching for empirical support for six theories used to explain elder abuse. Except for social learning theory, which had mixed results, all other theories were supported by empirical findings. These findings require some discussion to draw practice, research and theoretical implications. Can All the Theories Be Correct? The more striking result we found is that five of the six explored theories had more evidence in favour than against their theoretical predictions (the sixth is social learning theory, which had mixed results). These findings suggest that not one but rather all of these theories have a role in explaining abuse. To understand these findings is important to consider how these theories came to explain abuse against elderly individuals. Different authors adapted theoretical formulations from other fields to explain elder abuse (Roberto & Teaster, 2017). The result is a series of (apparently independent) theories that 80 Jackson, S. L., & Hafemeister, T. L. (2013). Understanding Elder Abuse: New Directions for Developing Theories of Elder Abuse Occurring in Domestic Settings. In Research in Brief, National Institute of Justice . National Institute of Justice. Jackson, S. L., & Hafemeister, T. L. (2016). Theory-based models enhancing the understanding of four types of elder maltreatment. International Review of Victimology , 22 (3), 289–320. https://doi.org/10.1177/0269758016630887 Kong, J, & Jeon, H. (2018). Functional Decline and Emotional Elder Abuse: a Population-Based Study of Older Korean Adults. Journal of Family Violence , 33 (1), 17–26. https://doi.org/10.1007/s10896017-9941-4 Kong, Jooyoung, & Easton, S. D. (2018). Re-experiencing Violence across the Life Course: Histories of Childhood Maltreatment and Elder Abuse Victimization. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences , 74 (5), 853–857. https://doi.org/10.1093/geronb/gby035 Korbin, J. E., Anetzberger, G. J., & Austin, C. (2005). The Intergenerational Cycle of Violence in Child and Elder Abuse. Journal of Elder Abuse & Neglect , 7 (1), 1–15. https://doi.org/10.1300/j084v07n01_01 Leung, D. Y. P., Lo, S. K. L., Leung, A. Y. M., Lou, V. W. Q., Chong, A. M. L., Kwan, J. S. K., Chan, W. C. H., & Chi, I. (2017). Prevalence and correlates of abuse screening items among community-dwelling Hong Kong Chinese older adults. Geriatrics and Gerontology International , 17 (1), 150–160. https://doi.org/10.1111/ggi.12655 MacNeil, G., Kosberg, J. I. J. I., Durkin, D. W. D. W., Dooley, W. K. K., Decoster, J., & Williamson, G. M. G. M. (2010). Caregiver mental health and potentially harmful caregiving behavior: The central role of caregiver anger. Gerontologist , 50 (1), 76–86. https://doi.org/10.1093/geront/gnp099 Mathew, A., & Nair, S. B. (2017). Theoretical Perspectives on Elder Abuse : A Framework Analysis for Abused Elderly in Kerala. IOSR Journal of Humanities and Social Science , 22 (9), 29–33. https://doi.org/10.9790/0837-2209042933 McDonald, L., & Thomas, C. (2013). Elder abuse through a life course lens. International Psychogeriatrics , 25 (8), 1235–1243. https://doi.org/10.1017/S104161021300015X Orfila, F., Coma-Solé, M., Cabanas, M., Cegri-Lombardo, F., Moleras-Serra, A., & Pujol-Ribera, E. (2018). Family caregiver mistreatment of the elderly: Prevalence of risk and associated factors. BMC Public Health , 18 (1), 1–14. https://doi.org/10.1186/s12889-018-5067-8 Özcan, N. K., Boyacıoğlu, N. E., & Sertçelik, E. (2017). Reciprocal Abuse: Elder Neglect and Abuse by 81 Primary Caregivers and Caregiver Burden and Abuse in Turkey. Archives of Psychiatric Nursing , 31 (2), 177–182. https://doi.org/10.1016/j.apnu.2016.09.011 Phillips, L. R., de Ardon, E. T., & Briones, G. S. (2001). Abuse of Female Caregivers by Care Recipients: Another Form of Elder Abuse. Journal of Elder Abuse and Neglect , 12 (3–4), 123–143. https://doi.org/10.1300/J084v12n03_06 Pillemer, K., & Finkelhor, D. (1989). CAUSES OF ELDER ABUSE: Caregiver Stress Versus Problem Relatives. American Journal of Orthopsychiatry , 59 (2), 179–187. https://doi.org/10.1111/j.19390025.1989.tb01649.x Pillemer, K., & Wolf, R. (1986). Elder abuse: Conflict in the family. Auburn House Publishing Co. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=psyc2&NEWS=N&AN=198698321-000 Post, L., Page, C., Conner, T., Prokhorov, A., Fang, Y., & Biroscak, B. J. (2010). Elder Abuse in LongTerm Care: Types, Patterns, and Risk Factors. Research on Aging , 32 (3), 323–348. https://doi.org/10.1177/0164027509357705 Reay, A. M. C., & Browne, K. D. (2001). Risk factor characteristics in carers who physically abuse or neglect their elderly dependants. Aging and Mental Health , 5 (1), 56–62. https://doi.org/10.1080/13607860020020654 Reay, A. M. C., & Browne, K. D. (2002). The Effectiveness of Psychological Interventions With Individuals Who Physically Abuse or Neglect Their Elderly Dependents. Journal of Interpersonal Violence , 17 (4), 416–431. https://doi.org/10.1177/0886260502017004005 Roberto, K. A., & Teaster, P. B. (2017). Theorizing elder abuse. In X. Q. Dong (Ed.), Elder Abuse: Research, Practice and Policy (pp. 21–41). Springer International Publishing. https://doi.org/10.1007/978-3-319-47504-2_2 Sasaki, M., Arai, Y., Kumamoto, K., Abe, K., Arai, A., & Mizuno, Y. (2007). Factors related to potentially harmful behaviors towards disabled older people by family caregivers in Japan. International Journal of Geriatric Psychiatry , 22 (3), 250–257. https://doi.org/10.1002/gps.1670 Schiamberg, L. B., Barboza, G. G., Oehmke, J., Zhang, Z., Griffore, R. J., Weatherill, R. P., von Heydrich, L., & Post, L. A. (2011). Elder abuse in nursing homes: An ecological perspective. Journal of Elder Abuse and Neglect , 23 (2), 190–211. https://doi.org/10.1080/08946566.2011.558798 Serra, L., Contador, I., Fernández-Calvo, B., Ruisoto, P., Jenaro, C., Flores, N., Ramos, F., & RiveraNavarro, J. (2018). Resilience and social support as protective factors against abuse of patients with dementia: A study on family caregivers. International Journal of Geriatric Psychiatry , 33 (8), 1132– 82 1138. https://doi.org/10.1002/gps.4905 Shinan-Altman, S., & Cohen, M. (2009). Nursing aides’ attitudes to elder abuse in nursing homes: The effect of work stressors and burnout. Gerontologist , 49 (5), 674–684. https://doi.org/10.1093/geront/gnp093 Shugarman, L. R., Fries, B. E., Wolf, R. S., & Morris, J. N. (2003). Identifying older people at risk of abuse during routine screening practices. Journal of the American Geriatrics Society , 51 (1), 24–31. https://doi.org/10.1034/j.1601-5215.2002.51005.x Stahl, S. M. (2015). 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Trauma, Violence, and Abuse , 20 (2), 197–213. https://doi.org/10.1177/1524838017692798 84 Chapter III Measuring social skills: cultural adaptation and validation of the SSI-Del Prette. Fundinho, J. F., Ferreira-Alves, J., Braz, A. C., Del Prette, Z. A. P., & Del Prette, A. (2021). Measuring social skills: cultural adaptation and validation of the SSI-Del Prette. The Journal of Adult Protection, 23 (5), 337-350. https://doi.org/10.1108/JAP-03-2021-0012 85 Abstract Purpose: Identifying and assessing social skills has been a powerful way of linking human behaviour and human interaction with their consequences at significant developmental levels. There are some data connecting social skills with interpersonal violence but not yet with elder abuse. The reason might be the scarcity of quick and easy-to-apply measures of social skills. This study aims to adapt and validate the Social Skills Inventory (Z. A. P. Del Prette & Del Prette, 2001) to the Portuguese population. Methodology: We conducted two studies. In study 1, we gathered the psychometric characteristics of the SSI-Del-Prette through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). In study 2, we correlated the new measure with measures of depression and empathy to test for divergent and concurrent validity. Findings: The obtained version of the SSI-Del-Prette showed a good model fit and internal consistency. This measure presented six factors: Conversation and social confidence , Easiness of self-exposure , Selfexpression of positive affect , Coping assertively with risk , Defending interests and opinions , Giving and receiving praise . The indicators of convergent and divergent validity supported the integrity of the measure. Originality/value: This paper provides an adaptation of a measure of six social skills expanded to the older adult population. Research limitations/implications: The adaptation of this measure of social skills opens new possibilities for studying these skills. Keywords : social skills, scale adaptation, validation, depression, empathy, adulthood 86 Measuring social skills: cultural adaptation and validation of the SSI-Del Prette Probably no one more than Carl Rogers in his seminal work (Rogers, 1952, 1992) stated so powerfully and clearly that, in adult life, the way people relate to each other (which we call social skills ) can be (or not be) supportive of human development and change. This support for human development means that people with higher social skills are more caring, more helpful, empathic, and ready to derive meaning from their interactions with others. Although this theory is appealing, it lacks the operationalisation that some authors provided later, pointing to microskills as the central verbal and nonverbal components of facilitating relationships in terms of counselling, psychotherapy, or teaching. However, social skills are not only essential for professionals who use personal relationships as the primary tool of their trade; social skills and interactions are important for every human being because of their role during several developmental stages within their protecting and challenging functions. For some authors, social skills are a determining part of social interactions and are vital as instruments, products, and by-products of different developmental challenges (Riggio et al., 1993). Beyond their link to human and psychosocial development, social skills (or their absence) are inextricably linked to interpersonal violence. Some authors have found a relationship between deficits in social skills and internalisation of problems, loneliness, depression, anxiety, and problem-solving skills (e.g., de Almeida & Benevides, 2018; Moeller & Seehuus, 2019; Salavera et al., 2019). Research in various contexts has suggested the importance of social skills for risk assessment, prevention, and treatment of some violent situations. In adolescents, social skills training significantly decreases the use of verbal violence (Babakhani, 2011), and children who experience bullying have significantly fewer social skills than children who do not (Fox & Boulton, 2005). Studies about the role of social skills in violence with adults are less frequent than studies about the role of social skills in violence with children and adolescents, and studies targeting older adults are even rarer. However, theoretical connections can be established between social skills and elder abuse. Some theoretical hypotheses that attempt to explain elder abuse base their predictions on the caregiver’s mental health or experience of stress - situational theory (Moore, 2019). In this regard, a lack of social skills has been related to the emergence of stress and mental health in adults (Segrin, 2019). Other explanations for elder abuse rely on the equilibrium between the perception of benefits and costs in a relationship - Social Exchange Theory (Moore, 2019). The relational competencies of both caregivers and older adults, and consequently social skills, are in this case of great importance for explaining elder abuse. Despite the absence of a clear connection between social skills and elder abuse, caregivers, older adults who receive care, care professionals point to social skills as fundamental for avoiding conflicts in care relationships, especially skills that involve 87 expressing positive feelings, controlling and preventing aggressiveness, and discussing problems (Pinto et al., 2016). One particular social skill has been more frequently used in intervention programmes in the context of older adult caregiving than any other; this social skill is assertiveness. For example, the START programme (Livingston et al., 2013), aimed at promoting mental health among caregivers of family members with dementia, includes a topic about assertive communication. This programme decreases depressive symptomatology and anxiety in family carers, which can be an important risk factor for abuse. Assertive communication has also been the focus of some prevention programmes aimed specifically at preventing elder abuse (Diaz Hernández et al., 2014; Fernández et al., 2012), but the effectiveness of the results are not clear. Although assertiveness is an important social skill, it is one of many competencies; the importance of the other skills remains untested and unexplored. Finally, we look to social skills as a foundation for best practices in caring for or helping people, mainly older adults. To that end, we will take advantage of the work of Stolee and collaborators (2012). By searching iteratively in literature reviews, internet reviews and stakeholder opinions, these authors constructed a set of proposals for planning and implementing best practices in the elder abuse domain. Specifically, these authors concluded that there is almost no evidence to carry out actual assessment and intervention strategies within that domain. Therefore, these authors recommended two strategies: “build capacity for research and program evaluation to advance knowledge of effective practices and build capacity for knowledge exchange to enhance professionals’ efforts” (p. 180). These recommendations fit very well with the need to translate to practice what we know when we have evidence from good research. If we consider some of the recommendations of Stolee and collaborators (2012) on what best practices surrounding elder abuse should include, we can see the obvious usability of virtually any measure of social skills. Their recommendations are: (a) “include the perspectives of older adults and victims in research, evaluation, and policy and procedure development”; (b) “use a client-centred approach (not “one size fits all”)”; (c) consider gender, family violence, and intergenerational approaches; (d) “be sensitive to variations in language, culture, ethnicity, religion, and Aboriginal identity”; and finally (e) “ensure coordination and integration across professionals/organisations” (p. 185). What could be a more direct way to train professionals (e.g., social workers, physicians, psychologists, nurses, and even researchers) within the scope of these recommendations than social skill education and training? In summary, we have enough evidence that social skills affect psychosocial development processes, the understanding and planning prevention of interpersonal violence, and implementing best practices within health and social care systems. 88 In the present paper, we aim to present psychometric data for a measure of social skills, the Social Skills Inventory–Del Prette (Z. A. P. Del Prette & Del Prette, 2001), collected from a Portuguese sample. Del Prette and Del Prette defined social skills as “a descriptive construct of the social behaviours valued in a particular culture with a high probability of favourable results for the individual, group and community that may contribute to a socially responsible performance in interpersonal tasks” (A. Del Prette & Del Prette, 2018, p. 24). From this conceptual standpoint, it is possible to classify social skills by their form (e.g. tone of voice, gestures, facial expressions) and functionality. Additionally, behaviours may have a similar function but might vary in form (A. Del Prette & Del Prette, 2018), which means that our social behaviour can vary quite a bit without changing its function. Another aspect to consider is the intimate relationship between social behaviours and social habits, making culture a determinant of the form and function of social skills. Cultural practices shape our social behaviour and influence social skills’ behavioural representations (Z. A. P. Del Prette & Del Prette, 2013). Additionally, social skills are ways of adaptation and coping. These are reasons enough to justify validating social skills measures, even from same-language countries, such as Portugal and Brazil. In the following paragraphs, we will present the measure for which we ran procedures of adaptation and validation. The Social Skills Inventory – Del Prette The Social Skills Inventory – Del Prette (Z. A. P. Del Prette & Del Prette, 2001) is a self-report instrument widely used in Brazil (Z. A. P. Del Prette & Del Prette, 2019); it assesses a range of social skills required in several kinds of everyday interpersonal situations. The items describe different skills in distinct contexts and their use in different interpersonal relationships. The scale’s original factor structure was composed of five factors, described by Z. A. P. Del Prette and Del Prette (2013). These factors represent classes of social skills, mainly organised by the functionality of the behaviour. The first factor is “Coping and self-assertion with risk” , referring to the skills needed to deal with interpersonal situations with assertiveness, entailing the possibility of an aversive reaction of the interlocutor (e.g. Item 16: “In a group of known people, if I do not agree with the majority, I verbally express my disagreement” ). The second factor is “Self-assertion in the expression of positive affect” and involves skills related to the expression of positive affect, showing appreciation and respect for others (e.g. Item 10: “I express affection by words or gestures to my family, friends and colleagues” ). The third factor is “Conversation and social confidence” and consists of skills required to conduct and 89 maintain a neutral social relationship, denoting knowledge of usual standards on daily relationships (e.g. Item 1: “In a group of unknown people, I am at ease, talking naturally” ). The fourth factor, “Self-exposure to unknown people and new situations” , comprises skills to approach unknown people (e.g. Item 23: “I avoid asking questions to unknown people” ). This factor is somewhat similar to the previous one but encompasses higher risk and exposure. The fifth factor, “Self-control of aggressiveness” , aggregates skills to control one’s anger and aggressiveness in aversive situations (e.g. Item 18- “When one of my relatives criticises me for some reason, I react aggressively” ). The original scale aimed to assess adults between 18 and 25 years old, and it was later extended to 59 years old (Z. A. P. Del Prette & Del Prette, 2018). Additionally, there is a version explicitly directed toward older adults, with differently worded items, removing references to school or work environments to target the elderly population (Braz et al., 2013). Given that some stability is expected in the performance of social skills classes, we opted to design a single version scale for those ages 18 and up. A possible disadvantage is that a single version, analytically speaking, is likely to focus on behaviours that remain more stable across the lifespan, thus focusing on skills that are less prone to change and, as a result, the measure will most likely have fewer items. Nevertheless, this version can be an important tool for exploring and understanding the relationship between social skills and human development. We present the data from this adaptation and validation in two studies. Study 1 focused only on the cultural adaptation of the SSI-Del-Prette and its psychometric characteristics. Study 2 centred on convergent and divergent validity by relating the factorial structure obtained in study 1 with two measures: a measure of empathy and one of depression. Study 1 The first study aimed to find a factorial structure of the SSI-Del-Prette for the Portuguese population and its associated psychometric characteristics. Participants Given the possible cultural variations in social behaviours, we opted for cross-validation. We gathered data from 287 participants, 215 (74.9%) of whom were female, ranging in age from 19 to 94 years (M=41.23; SD=23.26). Regarding marital status, 152 (53%) of the participants were single, 83 (28.9%) were married, 27 (9.4%) were widowers/widows, and 25 (8.7%) were divorced. Regarding education level, 10 (3.5%) participants attended but did not complete elementary school, 44 (15.3%) did complete elementary school, 6 (2.1%) completed middle school, 115 (40.1%) completed high school, and 96 Data Analysis First, we performed CFA on all measures, as Hair Jr and collaborators (2014) suggested as a good practice, following the same guidelines as in study 1. Second, we observed descriptive statistics of all of measures. Third, we used Pearson correlations to check the relationship between our version of the SSI-Del-Prette and the variables of Empathy and Depression. Results First, to confirm the factor structure of IRI, we conducted CFA. The four-factor structure presented acceptable model fit (χ2=96.409, df =48, p <.001, CFI=.926; RMSEA= .069; SRMR=.061). Internal consistency was acceptable (full-scale Cronbach’s α=.788; Fantasy CR=.66; Empathic concern CR=.73; Perspective-taking CR=.73; Personal Distress CR=.75). The BDI showed a previously reported two-factor (somatic-affective factor and cognitive factor) structure (Arnau et al., 2001) with good model fit (χ2=292.280, df =166, p <.001, CFI=.900; RMSEA=.060; SRMR=.060). It also showed good internal consistency (full-scale Cronbach’s α=.895; somatic-affective factor CR= .85; cognitive factor CR=.77). Descriptive statistics for all three measures are displayed in Table 4. Table 4 - Descriptive statistics of the variables social skills, depression, and empathy M (SD) (N=212) Min Max Social Skills (SSI-Del-Prette total score) 76.334 (11.279) 51 107 F1 - Conversation and social confidence 3.160 (.761) 1.33 5.00 F2 - Easiness of self-exposure 2.835 (.736) 1.00 4.80 F3 - Self-expression of positive affect 3.462 (.783) 1.75 5.00 F4 - Coping assertively with risk 3.553 (.796) 1.50 5.00 F5 - Defending interests and opinions 3.896 (.670) 1.67 5.00 F6 - Giving and receiving praise 4.310 (.592) 2.67 5.00 Depression (BDI) 7.948 (7.391) 0 41 Somatic-affective 5.406 (4.775) 0 22 Cognitive 2.382 (2.926) 0 18 Empathy (IRI) 114.009 (13.26) 79 155 Perspective-taking 4.342 (.713) 2.29 6 Empathic concern 4.767 (.632) 2.86 6 Fantasy 3.933 (.888) 2.29 5.86 Personal distress 3.246 (.795) 1.29 5.86 97 To test for convergent and divergent validity, we correlated the measure of depressive symptomatology (BDI) and the measure of empathy (IRI) with the social skills measured by the SSI-DelPrette. We expected that social skills would be positively associated with empathy and negatively associated with depressive symptoms, as previously justified. Table 5 presents the correlation coefficients between the SSI-De-Prette and the IRI and the BDI. Table 5 - Pearson correlations between SSI-Del-Prette factor scores and total score, and the total depressive symptomatology (BDI) and its subscales, and the measure of empathy (IRI) and its subscales. Total Score Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Depression (BDI) -.194** -.151* -.244** -.084 -.196** -.031 .005 Somatic-affective -.186** -.151* -.234** -.094 -.167* -.031 .001 Cognitive -.170* -.115 -.219** -.051 -.200** -.030 .005 Empathy (IRI) .123 .044 .030 .138* .005 .161* .226** Fantasy .080 .026 .057 .042 .066 .086 .068 Empathic concern .179** .163* .054 .210** -.037 .171* .320** Perspective-taking .314** .210** .150* .259** .155* .356** .277** Personal distress -.221** -.241** -.170* -.116 -.172* -.167* -.040 ** p < .01 * p < .05 Note: Factor 1 - Conversation and social confidence; Factor 2 - Easiness of self-exposure; Factor 3 - Selfexpression of positive affect; Factor 4 - Coping assertively with risk; Factor 5 - Defending interests and opinions; Factor 6 – Giving and receiving praise The main results indicate a negative correlation between the BDI and the SSI-De-Prette total score, and negative correlations between the BDI and “Conversation and social confidence” , “Easiness of self-exposure”, and “Coping assertively with risk” . “Self-expression of positive affect” , “Defending interests and opinions”, and “Giving and receiving praise” did not correlate with the BDI. The BDI subscales showed the same pattern, except for cognitive symptoms, which did not correlate significantly with “Conversation and social confidence” . Like in opposition, the total score for empathy correlated significantly and positively only with “Self-expression of positive affect” , “Defending interests and opinions”, and “Giving and receiving praise” . The IRI subscales revealed a more complex pattern. Fantasy did not correlate significantly with any indicator of the SSI-Del-Prette. Empathic concern showed the opposite pattern of the cognitive symptomatology subscale: it correlated positively with the total scale and “Conversation and social 98 confidence” , “Self-expression of positive affect” , “Defending interests and opinions”, and “Giving receiving praise” and did not correlate with “Easiness of self-exposure” and “Coping assertively with risk” . Perspective-taking correlated positively with all indicators of the SSI-Del-Prette. Personal distress revealed a similar pattern to the BDI and negatively with “Defending interests and opinions” . Discussion The main objective of study 2 was to present indicators of convergent and discriminant validity for our newly adapted SSI-Del-Prette. First, we tested the structure of the measures used for convergent and discriminant validity and deemed them acceptable. Second, we examined the descriptive statistics of the BDI and the IRI. Third, we correlated the measures as indicators of convergent and discriminant validity. The obtained results are congruent with the expected relations between the measures. Depressive symptomatology and social skills do not always have a clear relationship (Campos et al., 2018; Segrin, 2000). Our results suggest that for depressive symptoms, social skills might perhaps adopt a mediating role between depressive symptoms and other variables. We found negative correlations between depressive symptoms and “Conversation and social confidence” , “Easiness of self-exposure”, and “Coping assertively with risk”, but not with “Self-expression of positive affect” , “Defending interests and opinions”, or “Giving and receiving praise” . These results are congruent with Segrin and collaborators (2016), who proposed that depressive symptoms could relate to social skills but only as part of distress since the related factors seem to be the ones more likely to cause distress. A surprising outcome is the lack of relationship between the somatic-affective subscale and “Self-expression of positive affect” . Perhaps there is a difference between experiencing affective symptoms of depression and expressing affection to others. For the empathy measure, there was no correlation between the measures’ total scores, while we expected a positive association. This result might be because the total IRI score includes the score of Fantasy, which showed no relationship with social skills. The absence of a relation between Fantasy and social skills seems reasonable since no theoretical reason for this relationship exists. The relationships found with Empathic Concern make sense; the one relationship that could seem odd is with “Defending interests and opinions” , but this factor has an item about other people’s interests; therefore, some level of empathic concern is understandable. Perspective-taking is associated with all the SSI-Del-Prette indicators, which makes sense as taking the perspective of the people we interact with is essential to all the assessed skills. Last, the only difference between personal distress and the BDI is the negative relation 99 with “Defending interests and opinions” . This factor might lead to confrontation; this does not necessarily cause depressive symptomatology but quite likely causes personal distress. Hence, there is some logic in this outcome. The obtained correlations, in our view, support the discriminant and convergent validity of the SSI-Del-Prette, adding arguments in favour of its use. General Discussion The purpose of this article was to present a cultural adaptation of the SSI-Del-Prette (Z. A. P. Del Prette & Del Prette, 2001) for the Portuguese population and its psychometric characteristics. Moreover, we intended to show some evidence of the resulting measure’s divergent and convergent validity by associating it with a measure of depression and one of empathy. Due to cultural influence, social skills provide a challenge when one wants to validate measurement instruments (Z. A. P. Del Prette & Del Prette, 2013). Nevertheless, the variety of social skills training programmes (e.g. Braz et al., 2013; Turner et al., 2018) and the other research possibilities that emerge from this measure make its validation meaningful. However, a difficulty inherent in measures based on cultural behaviours is that they are ever-changing, making the process of adaptation and validation never definitive but always subject to re-evaluation. Regarding the convergent and divergent validity, the obtained results, as explored previously, were as expected and contribute as an indicator of quality for our version of the SSI-Del-Prette. However, this validation presents some limitations. First, we did not test the test-retest reliability, as was done with the original version (Bandeira et al., 2000). It is fundamental to test for temporal stability of a measure that can be used to gauge interventions. The second limitation is the absence of a comparison of the scale performance between genders. This comparison was not on our objective for this paper, but there could be gender differences in the use of social skills. Testing the metric invariance of this measure would clarify whether this version works equally well for men and women. We did not perform such a test due to the small number of male participants. Third, as an adaptation of a measure, we could have overlooked behaviours that are more common in the Portuguese population, which are part of the assessed social skills but were not present in the original items. Although Portugal and Brazil share a language, there are enough differences in social behaviour to suggest that some extra items could lead to a more similar set of classes as the ones suggested by the original authors (Z. A. P. Del Prette & Del Prette, 2018), even if our behavioural portfolios might vary. 100 Conclusion In summary, we generated a measure with good indexes of internal validity; this means that people reply differentially according to the dimensions of “ Conversation and social confidence ”, “ Easiness of self-exposure ”, “ Coping assertively with risk ”, “ Self-expression of positive affect ”, “ Defending interests and opinions ”, and “ Giving and receiving praise ”. Further, we obtained good indexes of external validity because this measure was significantly and positively linked to empathic concern and perspective-taking and negatively related to personal distress and depression. In our view, the measure validated in this paper and other measures of the same nature can be important tools to develop and assess intervention, prevention, and training programmes for professional or voluntary carers aimed at safeguarding adults. Although assertiveness has been a competence of interest for interventions with caregivers and older adults (e.g. Diaz Hernández et al., 2014; Livingston et al., 2013), other social skills may have a relevant role to play. The training and promotion of social competence can very well be a way to prevent elder abuse since it emerges in social relationships. Enhancing social skills can also be of value for the training of social and health professionals that work in adult protection. Social skills can be important competencies for professionals, contributing to better communication with patients and clients. These skills have the potential to enhance these interactions and perhaps even contribute to building safer social environments between professionals and adult victims. The previously stated connections between the social skills of professional caregivers, or even older adults themselves, regarding the quality of adult care provide a foundation for many future studies within the field as action research. The inclusion of social skills in the education of professionals can, in our view, benefit the realm of adult protection. A first step, however, needs to be the creation, adaptation, and validation of measures. We hope that this paper can provide researchers and professionals with an alternative to measure social skills and inspire the inclusion of these variables in the sphere of professional education to achieve adult protection. 101 References Anastácio, S., Vagos, P., Nobre-Lima, L., Rijo, D., & Jolliffe, D. (2016). The Portuguese version of the Basic Empathy Scale (BES): Dimensionality and measurement invariance in a community adolescent sample. 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T., McGlanaghy, E., Cuijpers, P., Van Der Gaag, M., Karyotaki, E., & MacBeth, A. (2018). A Meta-Analysis of Social Skills Training and Related Interventions for Psychosis. Schizophrenia Bulletin , 44 (3), 475–491. https://doi.org/10.1093/schbul/sbx146 105 Chapter IV Elder abuse as a social exchange: the role of cognition, functionality and social skills. Fundinho, J. F. & Ferreira-Alves, J. (2022). Elder abuse as a social exchange: the role of cognition, functionality and social skills . [Manuscript submitted for publication]. School of Psychology, University of Minho 112 and the number of errors. Two semantic categories were used in this study. The first one was the animals' category (Read, 1980), and the second category was things that could be bought at a supermarket (Strauss et al., 2006). Functionality We compiled the items of Barthel's Index (Mahoney & Barthel, 1965, Portuguese version by Sequeira, 2007) and Lawton-Brody's Index (Lawton & Brody, 1970, Portuguese adaptation by Azeredo & Matos, 2003) into a measure of three components of functionality. This approach was adopted because, through social exchange theory, we wanted to focus on specific forms of everyday dependence. Through Confirmatory Factor Analisis (CFA), described in the results section, we obtained three forms of functionality: movement, hygiene, and daily organization. Functionality for movement included all tasks that require physical acuity (e.g., climbing stairs). Hygiene included all tasks related to daily hygiene (e.g., bathing). The daily organization included tasks required for daily household maintenance (e.g., grocery shopping). The answers to both measures were standardized and coded in 3 points: 0 – Independent; 1 – Independent with assistance, and; 2 – Dependent. Social Skills The Social Skills Inventory – Del Prette (Del Prette & Del Prette, 2001), a Portuguese version by Fundinho et al. (2021), was used to assess social skills. The inventory is composed of 22 items, each describing behavior that requires applying a specific social skill. Participants rate the frequency of occurrence of each competency on a 5-point Likert scale, from 1 – Never to 5 – Always. Each item is part of one of six subscales representing six social skills. Subscales are Conversation and Social Confidence, Easiness of self-exposure, Self-expression of positive affect, Coping assertively with risk, Defending interests and opinions, and Giving and receiving praise. Each subscale score was obtained by calculating the mean of the answers. Higher scores represent the more frequent use of the assessed social skills. Also, a total score of social skills can be calculated by adding the response to all items. Abusive Behaviors Targeted at Older Adults We compiled a list of abusive behaviors based on previous instruments, abuse typologies, and scientific literature. The items were phrased to represent the theoretical model we adopted. The items describe specific behaviors that, by definition, constitute abuse (e.g., "Yelled at me" ). Phrasing the items as behaviors makes them conceptually exchange resources. The instruction to the participant asked to 113 think about interactions with the caregiver while responding. The list was composed of 32 behaviors, where eight were relative to physical abuse, and the remainder 24 were equally distributed to emotional, financial, neglect, and denial of rights. The participants were asked to identify which of the listed behaviors (if any) were experienced in the past year Procedure Data collection occurred in the context of a more extensive study that was submitted and approved by the ethics committee for social and human sciences of the University of Minho (SECSH 024/2016). All participants provided written informed consent. The data collection procedures took place during 2018 and were divided into two sessions of approximately 60 minutes. The rhythm of the sessions was adapted to the rhythm of the participant. The principal researcher conducted the sessions in an adequately lit and comfortable office provided by the day-care facilities. Every procedure was computerized, programmed for a touchscreen device with the approximate dimensions of a paper sheet using PsychoPy (Peirce & MacAskill, 2018). All instructions, questions, and answering options were presented on the screen and read aloud by the researcher. The touchscreen device was set at the same distance for every participant. The participant would use his/her fingertip to complete the tasks or select the answer for the questionnaires from the visual aid presented on the screen. Statistical Analysis The statistical analysis was conducted on the Statistical Package for the Social Sciences (SPSS). AMOS was used to test the model fit for the instruments used. Fit indexes were selected based on the recommendations of Brown (2006). As a support tool for moderation analysis, we used Andrew Hayes' PROCESS (Version 3.5) macro for SPSS (Hayes, 2013). To test our hypotheses, we used multiple stepwise (backward) regressions, hierarchical regressions, and simple slope analyses on the interaction effects. Results First, we will summarize the descriptive statistics of the assessed variables and then explore the relationship between cognitive skills and abuse. Lastly, we test the role of functionality and social skills in the relationship between cognition and elder abuse. 114 Descriptive Statistics Regarding the findings of the measurement of abuse, 20 participants (32.3%) reported having been the target of at least one of the enumerated abusive behaviors. Considering specific types of abuse, only 1 participant reported physical abuse. Its low frequency (no variance) did not allow for further statistical testing, and, for that reason, no further analyses were conducted for physical abuse. As for emotional abuse, it was reported by 8 participants (12.9%), financial exploitation and neglect were both reported by 9 participants (14.5%) each, and denial of rights was reported by 4 participants (6.5%). The list of abusive behaviors aimed at older adults showed excellent internal consistency (Cronbach's alpha = .96). The subscales for each type of abuse also showed acceptable values of internal consistency: emotional abuse (Cronbach’s alpha = .919); financial exploitation (Cronbach’s alpha = .903); negligence (Cronbach’s alpha = .812); and denial of rights (Cronbach’s alpha = .782). Concerning functionality, we started by testing the hypothesized three -factor structure using CFA. Three items were removed from the analysis, the two incontinence items from Barthel's Index and the medication item from Lawton-Brody's due to low variance. The three-factor solution for functionality was tested and showed adequate fit, χ2 = 113.252, df = 87, p = .031, CFI = .927; RMSEA = .070; SRMR=.076. The internal consistency was assessed by composite reliability (Hair, William, Babin, & Anderson, 2014), where CR is considered good above .70 but is acceptable above .60. In general, the factors showed good or acceptable values of CR: Movement (CR = .793); Hygiene (CR = .685); and Daily Organization (CR = .845). Regarding Movement, participants were mostly independent (M = .398; SD = .343), as they were with hygiene (M = .763; SD = .580). In daily organization, participants were mainly independent with help (M =1.229; SD = .578). Descriptive statistics for social skills are presented in Table 1. As for the cognitive skills assessed, means and standard deviations for the indicators of episodic memory, perceptual speed, and verbal fluency are also presented in Table 1. Regarding executive function, 32.3% of the participants could complete the TMT-part A in time, with an average of 1.98 errors (SD=2.433). Table 1 - Descriptive statistics for Episodic Memory, Perceptual Speed, Verbal Fluency and Social Skills. Min Max Mean (SD) Cognitive Skills Episodic Memory Total Recall 3 21 11.15 (4.284) Discrimination Index 0 24 15.45 (5.577) 115 Perceptual Speed .336 15.349 2.103 (3.366) Verbal Fluency Phonemic Fluency 0 22 6.21 (4.301) Semantic Fluency 2 16 7.87 (3.257) Social Skills Total 48 90 71.919 (10.815) Conversation and Social Confidence 1.33 5.00 3.199 (1.130) Easiness of self-exposure 1.00 3.80 1.652 (.746) Self-expression of positive affect 1.75 5.00 4.161 (.805) Coping assertively with risk 1.00 5.00 3.210 (1.196) Defending interests and opinions 1.00 5.00 3.855 (.980) Giving and receiving praise 2.00 5.00 4.339 (.811) Relationship Between Cognition and Elder Abuse To explore the relationship between cognition and elder abuse, we started by correlating the selected indicators of cognitive functioning and the different types of abuse. The correlation coefficients are presented in Table 2. Table 2 - Association between abusive behaviors by type and Episodic Memory, Perceptual Speed, Verbal Fluency, and Executive Function. Abusive Behaviors Emotional Financial Denial of rights Neglect Episodic Memory Total Recall .060 .129 .142 .066 -.114 Discrimination Index -.054 -.108 -.061 -.152 .047 Perceptual Speed .344** .244 .298* .152 .342** Verbal Fluency Phonemic Fluency .489** .454** .441** .303* .399** Semantic Fluency .257* .332** .179 .178 .205 Executive Function Completion Success .242 .193 .200 .276* .183 Number of Errors -.078 -.046 -.057 -.109 -.020 * p < .05 ** p < .01 Unlike in Dong and collaborators (2011), no relationship was found between episodic memory and elder abuse. As for perceptual speed, the relation found is congruent with the previous findings, where the longer it takes to process the letters, the higher the number of abusive behaviors reported. The exception for this relationship is emotional abuse and denial of rights. 116 When adding the two new indicators of cognitive function, we found a positive relationship between executive function, measured by the success to complete TMT-part A in time, and denial of rights. Regarding verbal fluency, phonemic fluency has a positive relationship with every type of abuse. In contrast, semantic fluency is only positively related to elder abuse total and emotional abuse, meaning that the more words a participant could enunciate in the first 15 seconds of each trial, the higher the number of abusive behaviors reported. To better understand how these cognitive indicators influence each other and predict the frequency of abusive behaviors, we conducted a series of regression analyses with two models: Model A considers only the previously identified predictors of elder abuse (episodic memory and perceptual speed), and Model B is a full model, including all cognitive indicators we have studied, in the regression. The first regression models were tested to predict the total number of abusive behaviors targeted at older adults based on their cognition, no matter the type of abuse. In Model A, a significant regression equation was found (F(3, 58) = 3.294, p =.027) with an R2 of .146. In this model, both indicators of episodic memory were not significant predictors of abusive behaviors, unlike perceptual speed. The number of abusive behaviors experienced increased by .799 for each second more it took the participant to process each letter. The full model (Model B) also presented a significant regression equation (F(7, 54) = 4.191, p =.001) with an R2 of .352. In this model, perceptual speed remained a significant predictor, where the number of abusive behaviors increased by .639 for every second more it took to process each letter. Also, Phonemic Fluency was a significant predictor, where the number of abusive behaviors increased by .610 for each word recalled. Put simply, for about every two seconds more of processing time or about two more words recalled in the Phonemic Fluency task, one more abusive behavior was reported. The same analysis was conducted for each type of abuse. A summary of these regression analyses is presented in Table 3. Denial of rights was the only form of abuse to show no significant regression equation and was, therefore, not included in any further analyses. Both models presented the same pattern in the case of neglect, with a positive association between perceptual speed and neglect. Model B explained more variance in financial abuse, and perceptual speed and phonemic fluency were the two significant predictors. Emotional abuse poses a more complex picture. In Model A, only perceptual speed is a significant predictor, but in the full model, there are changes. With the addition of the other cognitive variables, perceptual speed is no longer a significant predictor. The ability to discriminate between presented and not presented words in the episodic memory task becomes a significant predictor. The higher the ability to discriminate, the less reported abusive behaviors. Moreover, phonemic fluency also becomes a predictor, with an effect in the same direction as presented in financial abuse. 117 The Moderating Role of the Functionality on the Relationship Between Cognition and Abuse Considering the regression analysis results presented, we conducted a series of moderation analyses to test a set of predictions based on our conceptualization of an explanation for elder abuse based on social exchange theory. The regression analysis results showed which cognitive resources were essential predictors of elder abuse and, therefore, were the chosen predictors for the moderation analysis. To test the hypothesis of functionality acting as a moderator in the relationship cognition-abuse, we conducted a series of hierarchical regression analyses, summarized in Table 4 (for a graphical representation of the significant moderation effects, check the supplementary material – Appendix B). In the first step, we included the functionality and cognitive indicators. The predictor variables were centered, and interactions were calculated (Aiken & West, 1991). In the second step were included the interactions between predictors and moderators. With the addition of the interaction terms, all models accounted for a significantly higher proportion of the variance. In predicting the total number of abusive behaviors reported, there was a significant interaction between perceptual speed and dependency on daily organization tasks. Analyzing the conditional effect of the predictor at fixed values of the moderator, we realize that, for low levels of dependency for daily organization, every second more taken processing visual stimuli is associated with reporting almost two more abusive behaviors ( b = 1.736, t (54) = 5.191, p < .001). For medium levels of dependency for daily organization, there is no relationship between perceptual speed and abusive behaviors ( b = .253, t (54) = 1.022, p = .311). For high levels of dependency for daily organization, every second more taken in processing visual stimuli is associated with reporting one less abusive behavior ( b = -1.230, t (54) = - 4.130, p < .001). 118 Table 3 - B coefficient (Standard Error) from regression analysis where cognitive skills Episodic Memory, Perceptual Speed, Verbal Fluency and Executive Function are the predictors and Abusive behaviors are the outcome. Emotional Financial Denial of rights Neglect Model A Model B Model A Model B Model A Model B Model A Model B Episodic Memory Total Recall .109 (.062) .069 (.062) .106 (.060) .090 (.061) .046 (.037) .030 (.039) -.040 (.047) -.075 (.048) Discrimination Index -.085 (.048) -.096 (.046)* -.068 (.046) -.088(.045) -.050 (.029) -.055 (.029) .013 (.036) .011 (.036) Perceptual Speed .171 (.074)* .123 (.072) .194 (.071)** .150 (.071)* .066 (.044) .057 (.045) .148 (.056)* .123 (.056)* Verbal Fluency Phonemic Fluency .162 (.063)* .165 (.062)* .059 (.039) .093 (.049) Semantic Fluency .088 (.078) -.021 (.077) .008 (.049) .065 (.061) Executive Function Completion success .412 (.523) .571 (.515) .557 (.329) .430 (.410) Number of errors .059 (.100) .066 (.098) .009 (.063) -.006 (.078) R2 .127 .322 .146 .301 .077 .204 .128 .279 F 2.808* 3.667** 3.312* 3.322** 1.622 1.974 2.832* 2.985* Model A – Episodic Memory and Perceptual speed; Model B – full model with Episodic Memory, Perceptual speed, verbal fluency and executive function. * p < .05 ** p < .01 119 Table 4 - B coefficient (Standard Error) from hierarchical regression analysis testing main effects and the interaction with functionality. Abusive behaviors Emotional Financial Neglect Step 1 Step 2 Step 1 Step 2 Step 1 Step 2 Step 1 Step 2 Functionality Movements (Mov) 3.044 (3.705) 1.488 (2.400) 1.571 (.957) .708 (.833) 1.389 (.927) .584 (.838) -.187 (.778) -.502 (.555) Hygiene (Hyg) -1.124 (2.228) -2.188 (1.454) -.622 (.563) -.722 (.556) -.835 (.560) -1.247 (.576)* -.053 (.468) -.291 (.336) Daily Organization (DO) -2.102 (1.978) -.732 (1.291) -.438 (.503) .261 (.479) -.313 (.492) .495 (.462) -.343 (.415) -.068 (.298) Perceptual Speed (PS) .695 (.270)* .253 (.248) - - .085 (.070) .070 (.091) .143 (.057)* .034 (.057) Phonemic Fluency (PF) - - .234 (.053)*** .105 (.053) .189 (.054)** .122 (.052)* - - Episodic Memory (EM) - - -.062 (.042) -.030 (.037) - - - - PS × Mov -1.136 (.572) - -.426 (.239) -.143 (.132) PS × Hyg -.003 (.559) - .122 (.214) -.083 (.129) PS × DO -2.568 (.342)*** - -.341 (.128)* -.492 (.079)*** PF × Mov - .529 (.228)* .710 (.264)* - PF × Hyg - -.439 (.160)** -.444 (.165)* - PF × DO - -.201 (.102) -.012 (.105) - EM × Mov - -.536 (.182)** - - EM × Hyg - .241 (.102)* - - EM × DO - .033 (.092) - - R2 .147 .667 .287 .567 .276 .547 .147 .596 F 2.453 15.418*** 4.518** 5.945*** 4.269** 5.478*** 2.448 11.360*** * p < .05 ** p < .01 *** p < .001 120 As for emotional abuse, episodic memory and phonemic fluency were the predictors identified in the previous analysis. Dependency for movement and hygiene interacted significantly with both episodic memory and phonemic fluency. Starting with the interaction between phonemic fluency and dependency for movement, we found that at low levels of dependency ( b = -.077, t (50) = -.861, p = .393) and at medium levels dependency in movement ( b = .105, t (50) = 1.989, p = .052) there is no relationship between phonemic fluency and reporting behaviors consistent with emotional abuse. But, with more difficulties in movement, for each three and a half words recalled in the phonemic fluency task, one more emotionally abusive behavior is reported ( b = .286, t (50) = 2.888, p = .006). As for Hygiene interacting with phonemic fluency, we realize that at low levels of dependency for hygiene, for each three more words recalled in the phonemic fluency task, one more emotionally abusive behavior was reported ( b = .359, t (50) = 3.597, p = .001), while at medium ( b = .105, t (50) = 1.989, p = .052) and high levels ( b = -.150, t (50) = -1.322, p = .192), there was no association. Regarding the predictor episodic memory, and staring with the interaction with dependeny for movement, we realize that at low levels ( b = .154, t (50) = 1.907, p = .062) and medium levels of dependency for movement ( b = -.030, t (50) = -.809, p = .422), there is no association between episodic memory and emotional abuse. But, the more dependent the participant is moving around, for each five more points in the discrimination index of the episodic memory task , one less emotionally abusive behavior was reported ( b = -.214, t (50) = -3.339, p = .002). Also, at low levels of dependency for hygiene, for each six points in the discrimination index of the episodic memory task, one less emotionally abusive behavior was reported ( b = -.170, t (50) = -2.886, p = .006). At medium levels ( b = -.030, t (50) = -.809, p = .422) and high levels ( b = .110, t (50) = 1.377, p = .175) of dependence in hygiene tasks, there was no relationship between episodic memory and emotional abuse. Financial abuse had as predictors perceptual speed and phonemic fluency. Three significant interaction effects were found. First, there was an interaction between perceptual speed and dependency for daily organization. With less difficulties in the organization of daily tasks, four more seconds taken in processing visual stimuli were associated with reporting one more financially abusive behavior ( b = .267, t (50) = 2.105, p = .040), while at medium levels ( b = .070, t (50) = .764, p = .449) and at high levels ( b = -.127, t (50) = -1.191, p = .239) there was no predictive relationship. Second, regarding the interaction between phonemic fluency and movement, at lower levels of dependency in movement, there is no relationship between phonemic fluency and financial abuse ( b = -.122, t (50) = -1.209, p = .232), but at medium levels of movement there is an effect ( b = .122, t (50) = 2.364, p = .022), that triples at high levels of dependency in movement ( b = .366, t (50) = 3.384, p = .001), meaning that with higher difficulties in movement, for each three more words recalled in the phonemic fluency task, one more 121 financially abusive behavior is reported. The last interaction for financial abuse was between phonemic fluency and dependency for hygiene, where, at high levels of dependency, there is no predictive relation ( b = -.135, t (50) = -1.201, p = .235), but at medium levels there is an effect ( b = .122, t (50) = 2.364, p = .022) that more than triples at low levels of dependency in hygiene ( b = .380, t (50) = 3.634, p = .001), meaning that for the participants with less difficulties conducting their hygiene, for each two and a half more words recalled in the phonemic fluency task, one more financially abusive behavior was reported. Lastly, in neglect, the identified predictor was perceptual speed. The only significant interaction effect was between perceptual speed and dependency for daily organization. At low levels of dependence on daily organization tasks, for around three more seconds taken processing visual stimuli, one more neglectful behavior was reported ( b = .318, t (54) = 4.119, p < .001). At medium levels of dependency in daily organization there is no relationship ( b = .034, t (54) = .595, p = .554), but at high levels of dependence in daily organization, faster perceptual speed is associated with reporting less neglectful behaviors ( b = -.250, t (54) = -3.637, p = .001). The Moderating Role of Social Skills Between Cognition and Abuse To understand the moderating influence of social skills on the relationship between cognition and abuse, we used the cognitive indicators identified in Table 3. We conducted a series of hierarchical regression analyses, with the social skill included in the first step and the interaction in the second. Table 5 summarizes the analysis (for a graphical representation of the significant moderation effects, check the supplementary material). Conversation and social confidence, easiness of self-exposure, and giving and receiving praise did not affect the relationship between cognition and abuse. Self-expression of positive affect, coping assertively with risk, and defending interests and opinions affected different forms of abuse. Table 5 - B coefficient (standard error) at Step 2 of hierarchical regression analysis testing main effects for each social skill and the respective interaction terms with the cognitive indicators identified in Table 3: perceptual speed (PS), phonemic fluency (PF), and episodic memory (EM). Emotional Financial Neglect Conversation and Social Confidence (CSC) .067 (.219) .236 (.210) .220 (.159) PS × CSC - .089 (.069) .097 (.053) PF × CSC .044 (.062) .104 (.059) - EM × CSC -.025 (.046) - - R2 (Δ R2 ) .256 (.009)** .218 (.050)** .187 (.047)** Easiness of self-exposure (ESE) -.067 (.316) -.217 (.327) .117 (.265) 128 despite doing it constructively or not. Moreover, although assertiveness is considered competent social behavior, being assertive in a conversation does not mean that an agreement is reached, making assertive action frequently interpreted as impolite and inappropriate (Spitzberg, 1993). Therefore, these skills may decrease this subjective evaluation of the social value of a trade partner, and a less confrontational character might have more amenable exchanges. The results obtained with neglect also include the social skill self-expression of positive affect, and considering that neglect is a very particular form of abuse, this result also makes sense. Expressing positive affect can be regarded as equivalated to a type of reward that Blau (1964) refers to as "expressing esteem" in his conception of Social Exchange Theory. We could be before a case where the desired level of reciprocity of the exchange is not met. A person that expresses a positive affect with more frequency can feel neglected if the exchange return is less than expected. These results are, therefore, congruent with the tested theoretical explanation. Conclusions and Limitations This study has some limitations. The main limitation is assessing the concepts identified in social exchange theory. Assessing resources and the power/dependency balance in a relationship is challenging. The wide range of behavioral representations of these concepts makes it impossible to measure their full extent directly. We solved this challenge by assessing variables that are determinants for the availability and selection of resources and variables that we conceptualize as determining the balance between power and dependence, allowing us to collect evidence in support of this theory. Social exchange theory predicts that the availability of resources directly predicts the power/dependency balance. Following this prediction emerges another challenge: there are multiple forms of dependency, and we cannot be sure which resource predicts which form of dependency to test the causality chain predicted in theory. We approached this challenge using moderation analysis. Instead of focusing on difficult-to-determine causal links, we tried to understand how different indicators of power and dependency can alter the relationship between resources and abuse. In this way, our study still contributes favorable results in support of the social exchange theory. It can be thought of as a first step in studying this theory applied to elder abuse. It can also be argued that the sample size is small, but it was enough for one first exploration of this theoretical model. Several implications can be taken for theory, research and practice. Theoretical implications have been explored in this text, but the results generally support an underexplored theory of abuse, paving new ways to conceptualize abuse. Social exchange theory needs to be further explored. It can give way to new 129 forms of research in the field of elder abuse and possibly in the field of human psychological development. Finally, for practice, though these results are not enough for drastic changes, they indicate new necessities for risk assessment in elder abuse. The obtained results indicate that general measures of cognition that encompass several cognitive structures in one index might be misleading in assessing risk since not all cognitive structures seem to have the same weight in predicting abuse. It is also important to remember that different forms of abuse seem to be associated with different cognitive structures. Of major importance to risk assessment is also the role of power/dependency. It is very important to consider and assess multiple forms of dependency and power in relation to different resources. The conjugation of resources with power/dependency results in identifying different patterns of functioning, some that can be protective and others that can increase the risk of abuse. In this way, we establish more realistic risk assessment procedures. Plus, identifying what functioning patterns can be protective could significantly impact the development of preventive strategies for elder abuse. Beyond all the theoretical relevance of this theory to understanding why some relationships fail and become abusive, its more immediate usage could be educational, promoting new conceptions of human functioning in a relationship. Human relationships must be perceived as something that needs permanent study and never as something established or static. In conclusion, this study supports social exchange theory as an explanatory theory for elder abuse. 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Neuropsychologia , 43 (13), 1878–1886. 134 https://doi.org/10.1016/j.neuropsychologia.2005.03.013 135 Chapter V Emotion recognition, moral intuitions and elder abuse: a social exchange perspective. Fundinho, J. F. & Ferreira-Alves, J. (2021). Emotion recognition, moral intuitions and elder abuse: a social exchange perspective . [Manuscript submitted for publication]. School of Psychology, University of Minho 136 Abstract In this study, we operationalize and test some predictions of a social exchange theory of elder abuse. The theory proposes that a combination of low resources with high dependency/low relational power increase the older adult’s risk of abuse. We tested these predictions by exploring the association between emotion recognition, morality (resources) and abuse, moderated by functionality and social skills (indicators of dependence/power). We collected data from 62 participants between 64 and 94 years old. We found that the moral intuition harm/care was positively associated with the report of emotionally and financially abusive behaviors and denial of rights. The moral intuition authority/respect protected individuals from the same types of abuse. The effects of moral intuitions on the types of abuse increased in older adults with higher dependence on movement (denial of rights) and lower dependence on hygiene tasks (financial abuse and denial of rights). Likewise, these effects were more prominent in older adults with generally high social skills and low assertiveness. In summary, the results are congruent with a psychological interpretation of a social exchange theory of elder abuse and highlight the importance of relational models where moral intuitions interact with dependency and social skills to predict elder abuse. Keywords : elder abuse; social exchange theory; theories of abuse; emotion recognition; morality 137 Emotion recognition, moral intuitions and elder abuse: a social exchange perspective Elder abuse is defined as a single or repeated act (or absence of appropriate action) conducted by a person in whom the older adult trusts, resulting in harm or distress (World Health Organization, 2002). Numerous studies have been conducted in this area, mainly focusing on prevalence and risk factors for older adults and caregivers. However, theoretical development in this field has been scarce, despite being necessary for practical purposes; if a theoretical model can explain how abuse happens, it can help prevent abuse. A recent systematic review provided insight into how well theoretical models explain abuse (Fundinho, Pereira, et al., 2021). From this review, we learned that most theories have empirical support and that social exchange theory, as a broad theory, is a good starting point to organize the common attributes of other approaches and work on an integrated solution. Nevertheless, before that goal can be accomplished, it is necessary to look at elder abuse within the social exchange framework to understand it as a relational issue. However, relational models and variables have not been sufficiently studied. Therefore, this paper aims to examine elder abuse through social exchange theory and explore how personal characteristics that may direct our selection of behaviors in social interactions, namely, emotion recognition and moral intuitions, are related to elder abuse. Additionally, we aim to test whether these relations are affected by variables that impact the power/dependency balance, namely, functionality and social skills. Social exchange theory derives from many different fields of knowledge, including sociology, economics, and psychology. According to this theory, every social interaction is an exchange of resources, which can be material – e.g., trading money for an object – or nonmaterial – e.g., trading a favor for social acceptance - where both parties try to maximize rewards and reduce costs. A balanced exchange is an exchange where all involved parties feel that they have profited equally and, therefore, is mutually satisfying (Blau, 1964; Homans, 1961). Elder abuse does not occur in balanced exchanges but in unbalanced exchanges. If it becomes difficult for an older adult to produce or use resources and the needs increase, more exchanges are required to fulfill them. Increased needs while relying on limited possibilities for exchange leads to dependency on one person, typically the caregiver. One person’s dependence gives the other more power over the relationship. When an older adult is continually dependent on a caregiver, this is an unbalanced exchange. With more power, the caregiver can set the tone for future exchanges, always trying to maximize rewards (or cut losses). Some strategies used to maximize rewards may involve abusive behaviors. For example, a caregiver might withdraw from providing