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PEDIATRICS Vol. 108 No. 2 August 2001, pp. 508-512
Widespread efforts are continuously being made to
increase awareness and provide education to pediatricians regarding
risk factors of child abuse and neglect. The purpose of this statement is to ensure that children with disabilities are recognized as a
population that is also at risk for maltreatment. The need for early
recognition and intervention of child abuse and neglect in this
population, as well as the ways that a medical home can facilitate the
prevention and early detection of child maltreatment, should be
acknowledged.
ABSTRACT
Top
Abstract
Background
Recommendation
Conclusion
References
The maltreatment of children, including those with
disabilities, is a critical public health issue that must be addressed. The Third National Incidence Study of Child Abuse and Neglect showed
that the estimated number of abused and neglected children more than
doubled between 1986 and 1993.1 According to a report from
the National Child Abuse and Neglect Data System, child protective
services (CPS) agencies investigated nearly 2 million reports of
alleged maltreatment of an estimated 3 million children in
1995.2 More than 1 million children were identified as
victims of abuse and neglect during that year.
The numbers of children surviving disabling medical conditions as a
result of technologic advances and children being recognized and
identified as having disabilities are increasing.3 The
rates of child maltreatment have been found to be high with both the
child population in general as well as with children who are blind,
deaf, chronically ill, developmentally delayed, behaviorally or
emotionally disordered, and multiply disabled.4 Furthermore, child maltreatment may result in the development of
disabilities, which in turn can precipitate further
abuse.5 Previous studies have been unable to accurately
document the extent or rate of abuse among children with disabilities
or determine if disabilities were present before the abuse or were the
direct result of maltreatment.6 Little research on child
abuse has focused specifically on children with
disabilities.7
The Child Abuse and Prevention, Adoption, and Family Services Act
of 19888 mandated the study of the incidence of child
maltreatment among children with disabilities. This research was funded
by the National Center on Child Abuse and Neglect and conducted by the
Center for Abused Children With Disabilities at the Boys Town National
Research Center.4 A study by Westat Inc determined the
incidence of abuse among children with disabilities and the
relationship between child abuse and disabilities.7 Data
were collected from 35 CPS agencies across the country, and results
indicated that 14.1% of children whose maltreatment was substantiated
by CPS workers had 1 or more disabilities. Disabilities were found to
be twice as prevalent among maltreated children in hospitals as among
hospital controls, which is consistent with the hypothesis that
disabilities increase the risk for maltreatment. However, the data are
also consistent with the hypothesis that maltreatment contributes to
disabilities.9
According to the Boys Town National Research Hospital, children with
disabilities were found to be at greater risk of becoming victims of
abuse and neglect than children without disabilities. The study showed
that children with disabilities are 1.8 times more likely to be
neglected, 1.6 times more likely to be physically abused, and 2.2 times
more likely to be sexually abused than children without
disabilities.4 The study by Westat Inc determined that,
overall, the estimated incidence of maltreatment among children with
disabilities was 1.7 times greater than the estimated incidence in
children without disabilities.9 One study found the overall incidence of child maltreatment to be 39% in 150 children with
multiple disabilities admitted to a psychiatric hospital. Of those
children, 60% had been physically abused, 45% had been neglected, and
36% had been sexually abused.10
A major problem cited by literature is the definition of
"disabilities."6 There is currently no universal
definition of what constitutes a disability. The Americans With
Disabilities Act11 defines "disability" as a physical
or mental impairment that substantially limits 1 or more of the major
life activities of an individual. This definition includes all types of
disabilities, including physical disabilities, cognitive or learning
disabilities, motor and sensory dysfunctions, mental illness, or any
other kind of physical, mental, or emotional impairment.12
The term "developmental disability" applies to children who have
significant developmental delays, congenital abnormalities, or acquired
conditions that may result in disability if adequate resources and
services are not provided.13 The term "children with
special health care needs" is less limiting than some other terms.
Legal definitions do not always match clinical data. Child development
evaluations do not always allow an immediate and precise diagnosis of
disability, and some studies rely on evaluations by untrained
observers. Therefore, research efforts are hindered by
different definitions of terms (eg, disabilities and maltreatment), noncomparable methods, various study sample sizes, and lack of uniform
data collection. Furthermore, changes in reporting laws and societal
attitudes can occur during a study period.14
Another problem that has been cited in the literature is the lack of
recognition and documentation of disabilities by CPS workers and their
lack of training on evaluating children with disabilities.6 In the study by Westat Inc, analyses were based on CPS workers' opinions rather than data empirically derived from physicians or other professionals trained to diagnose
disabilities.7 Bonner et al demonstrated that since 1982, correct and consistent use of the CPS system of collecting information
regarding disabilities in maltreated children had decreased, suggesting
that disabilities were unlikely to be identified as children enter the
CPS system.6 A survey of 51 state CPS agencies found that
in 86% of states, CPS workers used a standardized form to record child
maltreatment cases, but in only 59% of those states did the workers
record information regarding preexisting disabilities on the
form.15
The Westat study was limited to intrafamilial cases.7
Because it is well known that individuals other than family members can
commit harm to children, statistics limited to intrafamilial cases
would be likely to underestimate the overall incidence of maltreatment
among children with disabilities.
In general, the causes of abuse and neglect of children with
disabilities are the same as those for all children; however, several
elements may increase the risk of abuse for children with disabilities.
Children with chronic illnesses or disabilities often place higher
emotional, physical, economic, and social demands on their
families.14 For example, a physical disability that causes
difficulty in ambulation can place a child at risk for accidental
falls. Therefore, close supervision would be needed. Parents with
limited social and community support may be at especially high risk for
maltreating children with disabilities, because they may feel more
overwhelmed and unable to cope with the care and supervision
responsibilities that are required.12 Lack of respite or
breaks in child care responsibilities can contribute to an increased
risk of abuse and neglect.
The requirement of special health and educational needs can result in
failure of the child to receive needed medications, adequate medical
care, and appropriate educational placements, resulting in child
neglect.12 Numerous problems have been cited with the
provision of care for foster children with disabilities. Foster parents
are sometimes not told about a child's medical and emotional problems
and are, therefore, not sufficiently educated or prepared to deal with
the specific condition. Other problems for foster children with
disabilities include lack of permanent placement, lack of a medical
home, lack of financial support, and failure to select appropriate
foster parents.5
Parents or caregivers may feel increased stress because children with
disabilities may not respond to traditional means of reinforcement, and
children's behavioral characteristics (ie, aggressiveness,
noncompliance, and communication problems, which may appear to be
temper tantrums) may become frustrating.4 A behaviorally
challenging child may further increase the likelihood of physical
abuse.12 Parents of children with communication problems
may resort to physical discipline because of frustration over what they
perceive as intentional failure to respond to verbal guidance. It has
been noted, however, that families who report higher stress levels may
actually have greater insight into problems associated with caring for
a disabled child, whereas parents with a history of neglect of a child
may not experience the level of stress that a more involved parent may
experience.16
In regard to sexual abuse, infrequent contact of a child with
disabilities with others may facilitate molestation, because there is
decreased opportunity for the child to develop a trusting relationship
with an individual to whom he or she may disclose the
abuse.12 Also, children who have increased dependency on
caregivers for their physical needs may be accustomed to having their
bodies touched by adults on a regular basis. Children with disabilities
who require multiple caregivers or providers may have contact with
numerous individuals, thereby increasing the opportunity for abuse.
However, an advantage to having a large number of caregivers is that
not only may someone detect the injuries or signs of abuse, but also
the amount of stress placed on the primary caregiver is decreased.
Children with disabilities often have limited access to critical
information pertaining to personal safety and sexual abuse prevention.
Parents may object to their child being provided with education on
human sexuality. Children with disabilities may also be conditioned to
comply with authority, which could result in them failing to recognize
abusive behaviors as maltreatment.4 Children with
disabilities are often perceived as easy targets, because their
intellectual limitations may prevent them from being able to discern
the experience as abuse. Impaired communication abilities may prevent
them from disclosing abuse. Because some forms of therapy may be
painful (eg, injections or manipulation as part of physical therapy),
the child may not be able to differentiate appropriate pain from
inappropriate pain.
Pediatricians should be aware that the presence of disabilities in
a child could be a risk factor for victimization and that disabilities
can also be the result of child maltreatment. The pediatrician should
work with families, other health care providers, and other community
resources to ensure the safety of all children.
Identification and Reporting
Pediatricians should always be alert to signs or symptoms that are
suggestive of abuse, no less in children with disabilities than in
others. However, recognizing the signs and symptoms of maltreatment
among children with disabilities may be difficult, because children may
not be able to verbalize that they were abused or they may not
understand that what took place was wrong.12 Children with
motor and balance disabilities may experience increased injuries from
accidents. However, children with neurosensory disabilities may be
predisposed to fractures, and in the absence of pain, there may be a
delay in seeking medical attention. Pediatricians and other
professionals who work with children must be aware of injury patterns
from inflicted versus noninflicted trauma. Signs and symptoms of
maltreatment in children with disabilities are commonly ignored,
misinterpreted, or misunderstood. Furthermore, many institutions may
have a disincentive to recognize or report child maltreatment because
of fear of negative publicity or loss of funding or licensure.
If abuse or neglect is suspected after a careful assessment, a report
must be made to the appropriate CPS agency. Every child suspected of
being abused or neglected should have a thorough evaluation by an
experienced professional trained in the field of child abuse and
neglect.17 The evaluation process should consist of a
structured interview with the child, if possible, and a comprehensive
physical examination, including appropriate laboratory and radiologic
studies.
Treatment
Appropriate medical treatment for injuries, infections, or other
conditions should be provided. Each case of abuse or neglect that is
clinically confirmed or strongly suspected should include a
multidisciplinary treatment plan, which includes a mental health therapy component appropriate for the child's cognitive and
developmental level and counseling for the family. This treatment plan
should be integrated with other intervention plans that may have
already been developed for the child. Federal legislation requires that each child identified as having a disability should have a written plan
of service (an Individual Family Service Plan [IFSP] for children
from birth through 2 years of age or an Individual Education Plan
[IEP] for children 3 through 21 years of age).17 A
recommendation may be the simple provision of protective gear for the
head or other anatomic regions to minimize the consequences of
accidental falls or impacts. Removal of the child from the home or
therapeutic foster care placement should be at the discretion of the
CPS agency after a thorough investigation.
Education
One study found that only 7 states require training in
disabilities for child welfare workers and that training averages 4 hours.17 In-service training for CPS workers, law
enforcement professionals, health care providers, child care
professionals, early childhood educators, teachers, and judges should
be provided; and protocols should be developed for the identification,
reporting, and referral of all cases of suspected child maltreatment in
all institutional settings. In addition, risk factors for maltreatment of children with disabilities should be emphasized. Health care providers should be trained to monitor children with disabilities for
signs of abuse and neglect and screen suspected victims of child
maltreatment for disabilities.13
Prevention
Support and assistance with parenting skills are often needed by
families with children with special health care needs. Medical and
nonmedical needs of the child and family should be addressed at each
health supervision visit. Child and family strengths should be
recognized and fostered at each encounter. Family stressors should be
addressed, and referrals for appropriate services should be made. The
availability of parent support groups, respite care, and home health
services, when appropriate, should be explored. Pediatricians should
educate parents of children with disabilities about respite waiver
subsidies and how to qualify for such funds as well as the need to get
on a waiting list as early as possible.
Children with disabilities need a medical home consisting of a health
care provider readily accessible to the family to answer questions,
help coordinate care, and discuss concerns.19 Developmental and behavioral pediatricians who are trained and experienced in the diagnosis and evaluation of children with
disabilities can also serve as excellent resources. Families should be
encouraged to work with a variety of disciplines and pursue resources
and services that they need. Child abuse prevention, including
indicators of abuse, should be discussed with parents and
caregivers.16
Advocacy
The physician must act as his or her patient's advocate by
assuming oversight and ultimate responsibility for the overall care
that is provided by the various agencies and resources, which can be
done by coordinating efforts and ensuring that recommendations are
conducted.19 By doing so, if child maltreatment is
suspected, the need for appropriate referrals can be immediately identified. State, educational, social, foster care, financial, and
health care systems often function in isolation from each other, with
very little coordination or communication.4 Community
involvement can also encourage the development of needed resources.
Foster children with disabilities and their foster parents often suffer
from lack of adequate support systems.6 Communication with
schools and other systems with which families with disabled children
interact is another avenue to heighten the awareness of the needs of
children with special health care needs.
As child advocates, pediatricians are in an ideal position to influence
public policy by sharing information and giving educational presentations on child maltreatment and the needs of children with
disabilities. They should advocate for state practices or policies that
mandate CPS agencies to gather disability information on child
maltreatment cases. This could help emphasize the devastating costs of
child maltreatment to lawmakers, policymakers, and the public.6 Pediatricians should also advocate for screening procedures for potential employees in educational, recreational, and
residential settings to help ensure the safety of all children in their
care.20
BACKGROUND
Top
Abstract
Background
Recommendation
Conclusion
References
INCIDENCE
CURRENT RESEARCH LIMITATIONS
CAUSAL FACTORS
PEDIATRICIAN'S ROLE
RECOMMENDATIONS
Top
Abstract
Background
Recommendation
Conclusion
References
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CONCLUSION |
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Top
Abstract
Background
Recommendation
Conclusion
References
|
|---|
The American Academy of Pediatrics supports the belief that pediatricians play a significant role in the prevention, identification, and treatment of child abuse and neglect, especially in children with disabilities, who may be at increased risk of maltreatment. Furthermore, children suspected of maltreatment should be evaluated for developmental disabilities. Pediatricians with experience in child abuse evaluations should provide training to other individuals. In addition, CPS workers and others involved in the investigation of child maltreatment should work closely with pediatricians to identify disabilities in children.12 Every effort should be made to ensure the safety of children through collaboration with families, other health care providers, schools, CPS agencies, and other appropriate resources.
Committee on Child Abuse and Neglect, 2000-2001
Steven W. Kairys, MD, MPH, Chairperson
Randell C. Alexander, MD, PhD
Robert W. Block, MD
V. Denise Everett, MD
Kent P. Hymel, MD
Carole Jenny, MD, MBA
Liaisons
David L. Corwin, MD
American Academy of Child and Adolescent Psychiatry
Gene Ann Shelley, PhD
Centers for Disease Control and Prevention
Section Liaison
Robert M. Reece, MD
Section on Child Abuse and Neglect
Staff
Tammy Piazza Hurley
Committee on Children With Disabilities, 2000-2001
Adrian D. Sandler, MD, Chairperson
Dana Brazdziunas, MD
W. Carl Cooley, MD
Lilliam González de Pijem, MD
David Hirsch, MD
Theodore A. Kastner, MD
Marian E. Kummer, MD
Richard D. Quint, MD, MPH
Elizabeth S. Ruppert, MD
Liaisons
William C. Anderson
Social Security Administration
Bev Crider
Family Voices
Paul Burgan, MD, PhD
Social Security Administration
Connie Garner, RN, MSN, EdD
US Department of Education
Merle McPherson, MD
Maternal and Child Health Bureau
Linda Michaud, MD
American Academy of Physical Medicine and Rehabilitation
Marshalyn Yeargin-Allsopp, MD
Centers for Disease Control and Prevention
Section Liaisons
Chris P. Johnson, MEd, MD
Section on Children With Disabilities
J. Daniel Cartwright, MD
Section on School Health
Staff
Karen Smith
| |
FOOTNOTES |
|---|
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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CPS, child protective services; IFSP, Individual Family Service Plan; IEP, Individual Education Plan.
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REFERENCES |
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Top
Abstract
Background
Recommendation
Conclusion
References
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The following policy statement is a revision:
This article has been cited by other articles:
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  R. A. Hibbard, L. W. Desch, and the Committee on Child Abuse and Neglect, and and Council on Children With Disabilities Maltreatment of Children With Disabilities Pediatrics, May 1, 2007; 119(5): 1018 - 1025. [Abstract] [Full Text] [PDF]
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 R. C. Tervo Identifying Patterns of Developmental Delays Can Help Diagnose Neurodevelopmental Disorders. Clinical Pediatrics, July 1, 2006; 45(6): 509 - 517. [PDF]
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N. A. Murphy, E. R. Elias, and for the Council on Children With Disabilities Sexuality of Children and Adolescents With Developmental Disabilities Pediatrics, July 1, 2006; 118(1): 398 - 403. [Abstract] [Full Text] [PDF]
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 M. Jonson-Reid, B. Drake, J. Kim, S. Porterfield, and L. Han A Prospective Analysis of the Relationship Between Reported Child Maltreatment and Special Education Eligibility Among Poor Children Child Maltreat, November 1, 2004; 9(4): 382 - 394. [Abstract] [PDF]
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 A. P. Sirotnak, T. Grigsby, and R. D. Krugman Physical Abuse of Children Pediatr. Rev., August 1, 2004; 25(8): 264 - 277. [Full Text] [PDF]
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P. A. DeRusso, M. R. Spevak, and K. B. Schwarz Fractures in Biliary Atresia Misinterpreted as Child Abuse Pediatrics, July 1, 2003; 112(1): 185 - 188. [Abstract] [Full Text] [PDF]
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