Presentation on theme: "Abuse in Children with Disabilities"— Presentation transcript:
1Abuse in Children with Disabilities The Pediatric PerspectiveWELCOME TO THE SESSION ON ABUSE IN CHILDREN WITH DISABILITIES: THE PEDIATRIC PERSPECTIVEI WOULD LIKE TO INTRODUCE MYSELF ####
2MY NAME IS JAMIE HOFFMAN-ROSENFELD MY NAME IS JAMIE HOFFMAN-ROSENFELD. TOM HANNA SUGGESTED THAT THE PARTICIPANTS MIGHT BE INTERESTED IN SEEING WHO IT WAS THAT WAS SPEAKING SO RIGHT BEFORE NIGHTFALL LAST NIGHT, MY SON TOOK THIS PICTURE OF ME.
4IN A BOROUGH CALLED THE BRONX, PERHAPS BEST KNOWN FOR BEING THE HOME OF THE HOUSE THAT RUTH BUILT – YANKEE STADIUM ####
5The CPC at the Children’s Hospital at Montefiore PERHAPS 5 MILES AWAY IS THE CHILDRENS HOSPITAL AT MONTEFIORE, A TERTIARY CARE CHILDREN’S HOSPITAL WHICH IS THE MAJOR AFFILIATE OF THE ALBERT EINSTEIN COLLEGE OF MEDICINE.THE CHILDREN’S HOSPITAL IS PROBABLY BEST KNOWN FOR ITS RECENT SUCCESS IN SEPARATING THE AGUIRRE TWINS WHO WERE UNTIL A FEW WEEKS AGO, JOINED AT THE TOP OF THEIR SKULLS.DOWN THE STREET FROM THE CHILDREN’S HOSPITAL IS THE CHILD PROTECTION CENTER OR CPC ###
6AS A FULLY ACCREDITED CHILD ADVOCACY CENTER, THE MONTEFIORE CPC IS A CHILD FRIENDLY PLACE WHERE MULTIDISCIPLINARY CHILD ABUSE EVALUATIONS TAKE PLACE. ###
7THIS IS A PICTURE OF OUR INTERVIEW SUITE, YOU ARE LOOKING THROUGH OUR ONE-WAY MIRROR INTO THE ROOM WHERE CHILDREN ARE INTERVIEWED WHILE BEING OBSERVED BY A HOST OF PROFESSIONALS INCLUDING, CHILD PROTECTION, LAW ENFORCEMENT AND MEDICAL ###
8THIS IS THE PLAY SET IN OUR BACK YARD THIS IS THE PLAY SET IN OUR BACK YARD. A LITTLE OVER ONE YEAR AGO, WE DECIDED TO TAKE ON A PROJECT WHICH HAD AS ITS MISSION IMPROVING THE APPROACH TO CHILD ABUSE IN CHILDREN WITH DISABILITIES BY EDUCATING ALL OF THE PROFESSIONALS INVOLVED AND BRIDGING THE GAP BETWEEN THE CHILDREN, THEIR FAMILIES, PROFESSIONALS IN THE DISABILITY FIELD AND MEMBERS OF THE CHILD ABUSE MULTIDISCIPLINARY TEAM. I HAVE TO TELL YOU, THAT DESPITE BEING A SEASONED PEDIATRICIAN WHO HAS BEEN WORKING PRIMARILY IN THE CHILD ABUSE FIELD FOR ABOUT 15 YEARS, WHEN I STARTED TO DELVE INTO THE ISSUES OF MALTREATMENT OF CHILDREN WITH DISABILITIES, I REALIZED THAT I REALLY HAD A LOT TO LEARN. I AM HONORED TO HAVE THE CHANCE TO SHARE SOME OF MY KNOWLEDGE WITH YOU.####
9Course Outline Definitions of maltreatment and disability Epidemiology The medical provider’s roleRecommendations by the American Academy of PediatricsAFTER I REVIEW THE COURSE OUTLINE AND THE LEARNING OBJECTIVES OF THE SESSION, I WILL LAUNCH INTO THE CONTENT. WE WILL TAKE TWO BREAKS DURING WHICH I WILL POST A “Quiz” QUESTION FOR YOU TO ANSWER AND AT THOSE TIMES I WILL ALSO ANSWER A FEW OF THE QUESTIONS THAT YOU POST TO ME BY GOING INTO THE CHAT ROOM ON YOUR CONSOLESTHE OUTLINE OF THIS COURSE IS………###
10Learning ObjectivesTo understand the relevant terminology including definitions of child maltreatment and disabilityTo understand the epidemiology including prevalence and risk factorsTo understand the role of medical providers including identification, reporting, education and advocacyTHE LEARNING OBJECTIVES ARE…….#####
11Definition of Disability The Americans with Disabilities ActA physical or mental impairment that substantially limits 1 or more of the major life activities of an individualTHERE IS NO UNIVERSALLY ACCEPTED DEFINITION OF DISABILITY BUT HERE IS ONE FROM THE AMERICANS WITH DISABILITIES ACT…….##
12DISABILITY DEFINITIONS Developmental Disability (as defined by the Federal Developmental Disabilities Act): A severe chronic disability which –Is manifested before age 22Is likely to continue indefinitelyResults in substantial functional limitations in 3 or more of the following (self-care, language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency)Reflects the individual’s need for a combination and sequence of special interdisciplinary or generic services, individualized support, and other forms of assistance that are lifelong or of extended duration and are individually planned and coordinated.A DEVELOPMENTAL DISABILITY (AS DEFINED BY……..#####
13Definition of Child Abuse and Neglect Federal Child Abuse Prevention and Treatment Act“at minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm”ONE DEFINITION OF CHILD ABUSE AND NEGLECT FROM THE FEDERAL…….####
14Let’s Look at Some of the Research! LET’S LOOK AT SOME RESEARCH ###
15State Efforts to Identify Maltreated Children with Disabilities Bonner, B.L., Crow, S,M. and Hensley, L.D.Child Maltreatment – 1997Only 7 states record disability status in abuse recordsIN THIS STUDY WHICH WAS PUBLISHED IN THE JOURNAL CHILD MALTREATMENT IN 1997, A MERE 7 YEARS AGO, BONNER ET AL LOOKED AT HOW MANY STATES RECORDED DISABILITY STATUS OF CHILDREN WHO WERE SUBJECTS OF AN ABUSE OR NEGLECT REPORT, IN ABUSE RECORDS.
16A Report on the Maltreatment of Children with Disabilities National Center on Child Abuse and NeglectCrosse, Kaye and Ratnofsky, 1993Data collected from CPS case files from 35 “representative” countiesCPS records capture primarily intra-familial abuseStudy relied on CPS worker opinion rather than disability diagnosis determined by appropriate trained professionalIN THIS STUDY, COMMISSIONED BY THE NATIONAL CENTER ON CHILD ABUSE AND NEGLECT,L DATA COLLECTORS WENT TO CPS RECORDS TO CAPTURE DATA ON CHILD ABUSE AND DISABILITIES, THE PROBLEM IS THAT THE DETERMINATION OF DISABILITY RELIED ON THE RECOGNITION OF DISABILITY AND ITS APPROPRIATE DOCUMENTATION IN THE CASE RECORDS BY CPS WORKERS. IN NEW YORK CITY, CPS WORKERS ARE ASKED TO WRITE IN THEIR NOTES WHETHER ANY MEDICAL CONDITIONS OR DISABILITIES ARE PRESENT BUT THEY ARE NOT GIVEN ANY TOOLS OR GUIDELINES ON HOW TO GATHER THE INFORMATION OR HOW TO MAKE THOSE ASSESSMENTS. YOU CAN SEE HOW A STUDY THAT RELIES ON CPS WORKERS AS THE PRIMARY SOURCE ON INFORMATION COULD HAVE SOME LIMITATIONS AND WHY ABUSE IN CHILDREN WITH DISABILITIES MIGHT BE UNDERRECOGNIZED ####
17Crosse, Kaye and Ratnofsky- findings 1834 American children in 1249 substantiated cases of child abuseRate of all types of abuse in children with disabilities was 1.7 times that in children without disabilitiesSexual abuse 1.8 times more likely in children with disabilities than in typically developing peers.DESPITE THE LIMITATIONS IN THIS STUDY, THESE RATES OF ABUSE IN CHILDREN WITH DISABILITIES ARE OFTEN QUOTED. ……..###
18Maltreatment and Disabilities; a population-based epidemiological study Sullivan, P.M. and Knutson, J.F.Boys Town National Research HospitalFunded by National Center on Child Abuse and NeglectChild Abuse and Neglect, October 2000PATRICIA SULLIVAN, WHO HOPEFULLY MANY OF YOU HAD THE CHANCE TO HEAR IN THE PREVIOUS HOUR, PUBLISHED THIS ELEGANT STUDY IN CHILD ABUSE AND NEGLECT IN 2000 ####
19Disability as defined by Nebraska Department of Education Children with disabilities shall mean those children who have been verified by a multidisciplinary evaluation team as children with autism, behavior disorders, deaf-blindness, hearing impairments, mental retardation, multiple disabilities, orthopedic impairments, other health impairments, traumatic brain injury or visual impairments, who because of these impairments need special education and related services8% of total school-based populationTHIS STUDY OF A SCHOOL BASED POPULATION IN OMAHA NEBRASKA USE A CAREFUL DETERMINATION OF DISABILITY, IT WAS…….###
20DISTRIBUTION OF DISABILITY TYPE THE FOUR BIGGEST CHUNKS OF THE PIE ARE LEARNING DISABILITIES, MENTAL RETARDATION, BEHAVIOR DISORDERS, AND HEALTH CONDITIONS####
21Sullivan and Knutson, 200050,278 children enrolled in Omaha Public SchoolsUsed school-based disability criterion (i.e. educationally mandated disabilities)Merged school records with Nebraska Dept. of Social Services, Nebraska Foster Care Review Board, and records from police department and sheriff’s officeTHE SCHOOL RECORDS WERE MERGED WITH RECORDS OF THE DEPARTMENTS OF………., THEY WERE LOOKING FOR HITS, MEANING CHILDREN WHO WERE DETERMINED TO HAVE A DISABILITY AND WHO WERE ALSO KNOWN OT THE CHILD PROTECTION SYSTEM BECAUSE THEY HAD BEEN MALTREATED ####
22Prevalence of Maltreatment in Children with Disabilities 31% of all children with disabilities are maltreated9% of children without disabilities are maltreatedChildren with disabilities are 3.4 X more likely to suffer abuse and neglect than children without disabilitiesTHIS IS WHAT THEY FOUNDIF YOU SEPARATE ALL OF THE CHILDREN IN THE SCHOOL SYSTEM INTO TWO GROUPS THOSE WITH DISABILITIES AND THOSE WITHOUT, ……. ####
23Prevalence Looking at it another way.. 22% of maltreated children had a disability(1012/4503)6% of non-maltreated children had a disability(2250/35,708)LETS LOOK AT IT ANOTHER WAY. PUT CHILDREN INTO TWO GROUPS BASED ON WHETHER OR OT THEY HAD BEEN MALTREATED. IN THE GROUP OF CHILDREN WHO HAD SUFFERED ABUSE, 22% HAD A DISABILITY, WHILE ONLY 6% OF THE NON-ABUSED GROUP OF CHILDREN HAD A DISABILITY WHICH SHOWS THAT CHILDREN WITH DISABILITIES ARE OVERREPRESENTED IN POPULATIONS OF MALTREATED CHILDREN. ####
24Relative Sexual Abuse Risk for Specific Disabilities 2.05.54.02.9PhysicalDisabilityImpairedHealthBehaviorDisorderDevelop.DelaySpeechAndLanguageTHIS STUDY ALSO LOOKED AT THE RELATIVE RISK OF VARIOUS TYPES OF ABUSE FOR SPECIFIC DISABILITIES. IF WE LOOK AT SEXUAL ABUSE IN PARTICULAR, CHILDREN WITH SPEECH AND LANGUAGE DISABILITIES WERE AT 2.9 TIMES THE RISK OF SEXUAL ABUSE, DEVELPMENTAL DELAY 4 TIMES THE RISK OF SEXUAL ABUSE, CHILDREN WITH BEHAVIOR DISORDERS AT 5.5 TIMES THE RISK OF SEXUAL ABUSE, ETC.All disabilities/All maltreatment (31/9)
25Relative Risk of Various Types of Maltreatment in Children with Behavior Disorders NeglectPhysicalAbuseEmotionalSexual7.05.5AND IT WE TAKE CHILDREN WITH BEHAVIOR DISORDERS WE SEE THAT THEY ARE AT 7 TIMES THE RISK OF NEGLECT, PHYSICAL ABUSE AND EMOTIONAL ABUSE THAN THEIR PEERS WITHOUT DISABILITY.
26Prevalence of Maltreatment Types Neglect most common type of maltreatment for children, both with and without disabilitiesMost children endure multiple types of maltreatmentNo significant association between type of disability and type of maltreatment
27Relationship between maltreatment and age Children with disabilities tend to be maltreated at younger ages that children without disability (preschool>elementary), therefore……Early intervention and support services critical for families with young children with disabilitiesCan target prevention efforts to period of maximum risk
28Relationship between maltreatment and gender Among children with disabilities, more boys are victims than girlsThe reverse is true in non-disabled childrenLikely reflects the greater prevalence of disabilities in males
30Children with disabilities are at low risk because people feel sorry for them.. Cognitive and communication limitations make reporting assaults/abuse less likelyChildren with disabilities are less likely to grow out of dependent stage, there is always a power differentialContact with a large number of service providers and alternate caretakers
31Children with intellectual disabilities do not know what is happening and will not suffer… No evidence to suggest that children with disabilities are less affected than other victimsChildren with disabilities may be at greater risk of emotional problems and impaired resiliency
32Children with disabilities can be made safe by restricting their contact with strangers…. The perpetrators of abuse are most likely to be family members, teachers, residential care providers and aides, including transportation.Reducing a child’s contacts may create a paucity of safe people in whom the child can confide.Offenders may seek employment in institutions designed to protect children with disabilities
33Children with disabilities could just say “NO” Tremendous power differential makes it very difficult for all children, but especially children with disabilities to say “no”Children with disabilities may have lack of experience with evaluative thinking, decision making and assertivenessChildren with developmental disabilities may be excluded from sex education and abuse prevention programs
34CONTRIBUTING FACTORSGreater emotional, physical, economic and social demands on their familiesLack of appropriate substitute caregivers--> no respite or breaks in child care responsibilitiesThe greater the health care and educational needs, the greater the opportunity for neglect of those needs
35CONTRIBUTING FACTORSChildren with behavior problems may be difficult to discipline.Children in foster care may lack permanent placement, medical home and appropriate foster parents with sufficient skills and education to handle the special needs of the child.
36Contributing Factors and Sexual Abuse Children may have increased dependency on caregivers for their physical needs and may be accustomed to having their bodies touched by adultsChildren may fear retribution by their caretakers if they were to tell about their sexual abuseMany alternate communication systems lack language for the intimate body parts and sexual acts
37Causal Factors and Sexual Abuse Children may be conditioned to comply with authorities and receive positive rewards for being passive or “easy to care for”Impaired communication may prevent their disclosing abuse.The child may not be able to discern that the event was abusive.
40PEDIATRIC HEALTH PROVIDERS GENERALIST PEDIATRICIANSSPECIALIST PEDIATRICIANSFAMILY PRACTITIONERSNURSE PRACTITIONERSPHYSICIAN ASSISTANTS
41MODERN ROLE OF THE PEDIATRIC HEALTH PROVIDER – INCLUDES: Providing immunizationsPreventing injuries with anticipatory guidanceDiscussing the child’s educationAdvising families on lifestyle goalsPromoting good health – ie.nutrition & exerciseCommunity ActivismBecoming an expert on abuse avoidance and recognitionTHE ROLE OF THE PRIMARY PEDIATRIC HEALTH CARE PROVIDER IS VERY DIFFERENT NOW THAN IT WAS EVEN YEARS AGO. WITH THE ADVENT OF NEW TECHNOLOGIES AND THE MOVE TOWARD TERTIARY CARE BEING IN THE PERVUE OF HIGHLY SUBSPECIALISED PEDIATRICIANS, THE PRIMARY CARE PROVIDER HAS NOT ONLY MORE TIME BUT THE DUTY TO DEALVE INTO THE PREVENTIVE AND HEALTH MAINTENANCE DOMAINS OF…….
42The Triad Child Parent/Abuser Triggering Crisis PEDIATRIC HEALTH PROVIDERS NEED TO UNDERSTAND HOW ELEMENTS RELATED TO THESE THREE FACTORS INTERACT TO CREATE AN ABUSIVE MILEAU. WHILE THESE CONCEPTS RELATE TO MALTREATMENT OF ALL CHILDREN, THEY ARE ESPECIALLY POWERFUL IN THE CASES OF CHILDREN WITH DISABILITIES
43Triad: The Child Child viewed as evil or different Prematurity, chronic illness, developmental disability or congenital defectBehavioral problemsPARENTS OF CHILDREN WITH DISABILITIES INCLUDING CHRONIC HEALTH CONDITIONS MAY FEEL GUILTY ABOUT THEIR CHILD’S PROBLEM, THEY MAY FEEL THAT IT IS DUE TO SOMETHING THEY DID OR DID NOT DO. THEY MAY BE ANGRY AND FRUSTRATED THAT THEIR CHILD HAS NOT FULFILLED THEIR EXPECTATIONS. THEY MAY BE DEPRESSED AND MOURN the LOSS OF THEIR IDEAL OF A PERFECT CHILD.BY THE WAY, THIS SLIDE HAS BEEN PART OF MY GENERAL PRESENTATION ON THE RECOGNITION OF CHILD ABUSE AND NEGLECT FOR MANDATED REPORTERS. UP UNTIL ABOUT ONE AND HALF YEARS AGO WHEN I BEGAN MY ODYSSEY INTO THIS PARTICULAR FIELD, IT WAS THE ONLY SLIDE IN MY LECTURE THAT DEALT WITH THE VULNERABILITY OF CHILDREN WITH DISABILITIES. ###
44Triad: The Parent/Abuser Abused as a childPoor self conceptLow intelligenceAdolescentUnrealistic expectationsAbsence of nurturingPoor mental or physical health
45Triad: Triggering Crisis Social isolation/single parent householdsMarital problems/domestic violenceSubstance abuseLoss of incomeHomelessness
46HEALTH CARE PROVIDERS IDENTIFICATION While recognizing the particular vulnerability of children with disabilities, providers must always be alert to signs or symptoms of abuse and neglectProviders must be familiar with injury patterns of inflicted vs. non-inflicted injuriesProviders must not assume that changes in behavior are simply manifestations of the child’s disabilityInjuries must not be assumed to be related to the child’s disability
51Physical Abuse Behavioral Characteristics: Overly passive or aggressiveFear of going homeInconsistent explanation of injuriesWears concealing clothingLow self esteem and blames self for abuseBehavioral difficulties
52Physical Abuse History: Who, What, When, Where, How? Clues that should heighten suspicion:Parental lack of cooperationInappropriate reactionsParental expression of guilt or fearSigns of addiction in the caretakerTension or hostility between caretakersInconsistent historyDelay in seeking medical care
53Physical Abuse Further clues to heighten suspicion: A child readily admits that an adult hurt him“Partial confessions”A parent denies knowledge of significant injuriesA parent claims that the injury was caused by a sibling
56HEALTH CARE PROVIDERS REPORTING If abuse or neglect is suspected, a report must be made to the appropriate child protection agencyNo assumption should be made about the guilt or innocence of the adult who has brought the child for care.Refer to a Child Advocacy Center &/or call for consultation, when availableCooperate with the investigation
57HEALTH CARE PROVIDERS TREATMENT Providers must treat injuries and infections appropriatelyAssure that CPS is aware of the child’s medical and disability statusAssure that a “medical home” is maintained if a child goes into careProvide a written summary of medications, equipment, therapies and other necessary services
58HEALTH CARE PROVIDERS EDUCATION Pediatric health care providers are uniquely qualified to educate CPS workers, law enforcement, child care professionals, educators, and judges about signs and symptoms of child abuse AND the vulnerability of children with disabilities
59HEALTH CARE PROVIDERS PREVENTION Assure prompt referral to Early Intervention so that an Individual Family Service Plan can be developedIdentify and explore family stressorsProvide support and assistance to families of children with disabilities –parenting skills programssupport groupshome health servicesrespite care
63HEALTH CARE PROVIDERS PREVENTION Be on the lookout for parental depression and other mental health problemsScreen for Domestic ViolenceServe as the coordinator of careRecognize and foster child and family strengths
64HEALTH CARE PROVIDERS PREVENTION Talk to parents about discipline and teach nonviolent strategies for handling difficult and inappropriate behaviorsEducate parents about the vulnerability of their child with disabilities – in a supportive waywhat can parents be on the lookout forencourage involvement in their child’s school and familiarity with the people who will be working with their childlook for programs with open spaces and staff supervision
65HEALTH CARE PROVIDERS PREVENTION Talk to the parents about appropriate sexuality educationEncourage parents to provide their children with the words to use and the opportunities to tell them if something has happened
66HEALTH CARE PROVIDERS ADVOCACY – work within professional organizations to: Promote a positive image of children, youth and adults with disabilities.Enforce the Americans with Disabilities Act and other laws relating to disabilities and inclusion. Implement new laws.Increase public awareness of the problem through advertising and media.Increase funding for research on the relationship between disability and maltreatment.
67HEALTH CARE PROVIDERS ADVOCACY Advocate for state practices or policies that require CPS agencies to screen children, who are involved in child abuse investigations, for disabilitiesAdvocate for screening procedures for potential employees of educational, residential and recreational settings for children with disabilities
69AMERICAN ACADEMY OF PEDIATRICS AUGUST, 2001 SUMMARYAMERICAN ACADEMY OF PEDIATRICSAUGUST, 2001
70AAP RECOMMENDATIONSAll pediatricians should be capable of recognizing signs and symptoms of child maltreatment in all children and adolescents, including those with disabilities.Because children with disabilities may be at increased risk for maltreatment, pediatricians should be vigilant not only in their assessment for indications of abuse but also in their offerings of emotional and instrumental support.
71AAP RECOMMENDATIONSPediatricians should ensure that any child in whom abuse has been identified is thoroughly evaluated for disabilities.All children with disabilities should have a medical home.Pediatricians should be actively involved with treatment plans developed for children with disabilities.
72AAP RECOMMENDATIONSHealth supervision visits should be used as a time to assess a family’s strengths and need for resources to counterbalance family stressors and parenting demands.Pediatricians should advocate for changes in state and local policies in which system failures seem to occur regarding identification, treatment, and prevention of maltreatment of children with disabilities.Pediatricians should advocate for better health care coverage by both private insurers and governmental funding.
73THANK YOU FOR PARTICIPATING IN THE SESSION PLEASE FILL OUT THE EVALUATION!