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Abuse in Children with Disabilities The Pediatric Perspective.

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Presentation on theme: "Abuse in Children with Disabilities The Pediatric Perspective."— Presentation transcript:

1 Abuse in Children with Disabilities The Pediatric Perspective




5 The CPC at the Children’s Hospital at Montefiore




9 Course Outline Definitions of maltreatment and disability Epidemiology The medical provider’s role Recommendations by the American Academy of Pediatrics

10 Learning Objectives To understand the relevant terminology including definitions of child maltreatment and disability To understand the epidemiology including prevalence and risk factors To understand the role of medical providers including identification, reporting, education and advocacy

11 Definition of Disability The Americans with Disabilities Act A physical or mental impairment that substantially limits 1 or more of the major life activities of an individual

12 DISABILITY DEFINITIONS Developmental Disability (as defined by the Federal Developmental Disabilities Act): A severe chronic disability which – – Is manifested before age 22 – Is likely to continue indefinitely – Results 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.

13 Definition 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”

14 Let’s Look at Some of the Research!

15 State Efforts to Identify Maltreated Children with Disabilities Bonner, B.L., Crow, S,M. and Hensley, L.D. Child Maltreatment – 1997 Only 7 states record disability status in abuse records

16 A Report on the Maltreatment of Children with Disabilities National Center on Child Abuse and Neglect Crosse, Kaye and Ratnofsky, 1993 Data collected from CPS case files from 35 “representative” counties CPS records capture primarily intra-familial abuse Study relied on CPS worker opinion rather than disability diagnosis determined by appropriate trained professional

17 Crosse, Kaye and Ratnofsky- findings 1834 American children in 1249 substantiated cases of child abuse Rate of all types of abuse in children with disabilities was 1.7 times that in children without disabilities Sexual abuse 1.8 times more likely in children with disabilities than in typically developing peers.

18 Maltreatment and Disabilities; a population-based epidemiological study Sullivan, P.M. and Knutson, J.F. Boys Town National Research Hospital Funded by National Center on Child Abuse and Neglect Child Abuse and Neglect, October 2000

19 Disability 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 services 8% of total school-based population


21 Sullivan and Knutson, ,278 children enrolled in Omaha Public Schools Used 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 office

22 Prevalence of Maltreatment in Children with Disabilities 31% of all children with disabilities are maltreated 9% of children without disabilities are maltreated Children with disabilities are 3.4 X more likely to suffer abuse and neglect than children without disabilities

23 Prevalence 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)

24 Relative Sexual Abuse Risk for Specific Disabilities Physical Disability Impaired Health Behavior Disorder Develop. Delay Speech And Language All disabilities/All maltreatment 3.4 (31/9)

25 Relative Risk of Various Types of Maltreatment in Children with Behavior Disorders NeglectPhysical Abuse Emotional Abuse Sexual Abuse

26 Prevalence of Maltreatment Types Neglect most common type of maltreatment for children, both with and without disabilities Most children endure multiple types of maltreatment No significant association between type of disability and type of maltreatment

27 Relationship 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 disabilities Can target prevention efforts to period of maximum risk

28 Relationship between maltreatment and gender Among children with disabilities, more boys are victims than girls The reverse is true in non-disabled children Likely reflects the greater prevalence of disabilities in males


30 Children with disabilities are at low risk because people feel sorry for them.. Cognitive and communication limitations make reporting assaults/abuse less likely Children with disabilities are less likely to grow out of dependent stage, there is always a power differential Contact with a large number of service providers and alternate caretakers

31 Children 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 victims Children with disabilities may be at greater risk of emotional problems and impaired resiliency

32 Children 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

33 Children 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 assertiveness Children with developmental disabilities may be excluded from sex education and abuse prevention programs

34 CONTRIBUTING FACTORS Greater emotional, physical, economic and social demands on their families Lack of appropriate substitute caregivers --> no respite or breaks in child care responsibilities The greater the health care and educational needs, the greater the opportunity for neglect of those needs

35 CONTRIBUTING FACTORS Children 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.

36 Contributing 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 adults Children may fear retribution by their caretakers if they were to tell about their sexual abuse Many alternate communication systems lack language for the intimate body parts and sexual acts

37 Causal 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.




41 MODERN ROLE OF THE PEDIATRIC HEALTH PROVIDER – INCLUDES: Providing immunizations Preventing injuries with anticipatory guidance Discussing the child’s education Advising families on lifestyle goals Promoting good health – ie.nutrition & exercise Community Activism Becoming an expert on abuse avoidance and recognition

42 The Triad Child Parent/Abuser Triggering Crisis

43 Triad: The Child Child viewed as evil or different Prematurity, chronic illness, developmental disability or congenital defect Behavioral problems

44 Triad: The Parent/Abuser Abused as a child Poor self concept Low intelligence Adolescent Unrealistic expectations Absence of nurturing Poor mental or physical health

45 Triad: Triggering Crisis Social isolation/single parent households Marital problems/domestic violence Substance abuse Loss of income Homelessness

46 HEALTH CARE PROVIDERS IDENTIFICATION While recognizing the particular vulnerability of children with disabilities, providers must always be alert to signs or symptoms of abuse and neglect Providers must be familiar with injury patterns of inflicted vs. non-inflicted injuries Providers must not assume that changes in behavior are simply manifestations of the child’s disability Injuries must not be assumed to be related to the child’s disability





51 Physical Abuse Behavioral Characteristics: – Overly passive or aggressive – Fear of going home – Inconsistent explanation of injuries – Wears concealing clothing – Low self esteem and blames self for abuse – Behavioral difficulties

52 Physical Abuse History: Who, What, When, Where, How? Clues that should heighten suspicion: – Parental lack of cooperation – Inappropriate reactions – Parental expression of guilt or fear – Signs of addiction in the caretaker – Tension or hostility between caretakers – Inconsistent history – Delay in seeking medical care

53 Physical Abuse Further clues to heighten suspicion: – A child readily admits that an adult hurt him – “Partial confessions” – A parent denies knowledge of significant injuries – A parent claims that the injury was caused by a sibling



56 HEALTH CARE PROVIDERS REPORTING If abuse or neglect is suspected, a report must be made to the appropriate child protection agency No 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 available Cooperate with the investigation

57 HEALTH CARE PROVIDERS TREATMENT Providers must treat injuries and infections appropriately Assure that CPS is aware of the child’s medical and disability status Assure that a “medical home” is maintained if a child goes into care Provide a written summary of medications, equipment, therapies and other necessary services

58 HEALTH 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

59 HEALTH CARE PROVIDERS PREVENTION Assure prompt referral to Early Intervention so that an Individual Family Service Plan can be developed Identify and explore family stressors Provide support and assistance to families of children with disabilities – parenting skills programs support groups home health services respite care

60 Chaotic Home

61 Crack Pipe

62 Family Violence

63 HEALTH CARE PROVIDERS PREVENTION Be on the lookout for parental depression and other mental health problems Screen for Domestic Violence Serve as the coordinator of care Recognize and foster child and family strengths

64 HEALTH CARE PROVIDERS PREVENTION Talk to parents about discipline and teach nonviolent strategies for handling difficult and inappropriate behaviors Educate parents about the vulnerability of their child with disabilities – in a supportive way what can parents be on the lookout for encourage involvement in their child’s school and familiarity with the people who will be working with their child look for programs with open spaces and staff supervision

65 HEALTH CARE PROVIDERS PREVENTION Talk to the parents about appropriate sexuality education Encourage parents to provide their children with the words to use and the opportunities to tell them if something has happened

66 HEALTH 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.

67 HEALTH CARE PROVIDERS ADVOCACY Advocate for state practices or policies that require CPS agencies to screen children, who are involved in child abuse investigations, for disabilities Advocate for screening procedures for potential employees of educational, residential and recreational settings for children with disabilities



70 AAP RECOMMENDATIONS All 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.

71 AAP RECOMMENDATIONS Pediatricians 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.

72 AAP RECOMMENDATIONS Health 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.


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