CLINICAL REPORT

Maltreatment of Children With Disabilities Roberta A. Hibbard, MD, Larry W. Desch, MD, and the Committee on Child Abuse and Neglect

and Council on Children With Disabilities

ABSTRACT Widespread efforts are being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population that is also at risk of maltreatment. Some conditions related to a disability can be confused with 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 maltreat- ment, are the subject of this report.

INTRODUCTION The maltreatment of children, including those with disabilities, is a critical public health issue. For purposes of this report, the terms “disability” and “special health care needs” include the full spectrum of physical, mental, and emotional impair- ment. Current data on incidence and prevalence of maltreatment in children with disabilities are limited by varying definitions of disability and lack of uniform methods of classifying maltreatment. Nonetheless, children with disabilities and special health care needs are at increased risk of child maltreatment. This report is an update to the previous policy statement, “Assessment of Maltreatment of Children With Disabilities.”1

The Children’s Bureau reported that an estimated 872 000 children were de- termined to be victims of abuse or neglect in 2004.2 More than 60% of child victims experienced neglect, almost 20% were physically abused, and 10% were sexually abused. Of the 36 states that reported on disabilities, child victims who were reported with a disability accounted for 7.3% of all victims. Children with the following conditions were considered as having a disability: mental retardation, emotional disturbance, visual impairment, learning disability, physical disability, behavioral problems, or another medical problem. It was believed that these conditions were underrecognized and underreported, because not every child received a clinical diagnostic assessment when child maltreatment was suspected.

Child maltreatment may result in the development of disabilities, which in turn can precipitate further abuse.3 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 maltreat- ment.4 It should be emphasized also that several case reports and epidemiologic data remind us that the natural history of some medical conditions can include conditions that mimic child maltreatment.5,6

www.pediatrics.org/cgi/doi/10.1542/ peds.2007-0565

doi:10.1542/peds.2007-0565

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

KeyWords child neglect, child maltreatment, developmental disabilities, child abuse, physical abuse, child sexual abuse

Abbreviations CPS—child protective services AAP—American Academy of Pediatrics

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2007 by the American Academy of Pediatrics

1018 AMERICAN ACADEMY OF PEDIATRICS

Guidance for the Clinician in Rendering Pediatric Care

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The numbers of children who survive disabling med- ical conditions as a result of technologic advances and children who are recognized and identified as having disabilities are increasing.7 The rates of child maltreat- ment have been found to be high in the child population in general and in children with blindness, deafness, chronic illness, developmental delays, behavioral or emotional disorders, and multiple disabilities.8 Minimal research on child abuse has focused specifically on chil- dren with disabilities; further study is indicated and has been encouraged.9,10

The Child Abuse and Prevention, Adoption, and Fam- ily Services Act of 1988 (Pub L No. 100–294) included a mandate to study 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 Chil- dren With Disabilities at the Boys Town National Re- search Center.8 A study by Westat, Inc, determined the incidence of abuse among children with disabilities and the relationship between child abuse and disabilities.9

Data were collected from 35 child protective services (CPS) agencies across the country, and results indicated that 14.1% of children whose maltreatment was sub- stantiated by CPS workers had 1 or more disabilities. A Nebraska study that used an electronic merger of hospi- tal, central registry, foster care review board, and law enforcement records found disabilities 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 of maltreat- ment. The data are also consistent with the hypothesis that maltreatment contributes to disabilities.11

According to research performed by the Boys Town National Research Hospital, children with disabilities were found to be at greater risk of becoming victims of abuse and neglect than were children without disabili- ties. 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 are children without disabil- ities.8 Another 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.12 In a 2000 study of more than 4500 maltreated children, Sullivan and Knutson13 observed children with disabili- ties to be 3.76 times more likely to be neglected, 3.79 times more likely to be physically abused, and 3.14 times more likely to be sexually abused when compared with children without disabilities.13 Children with behavioral disorders were found to be at the highest risk of all types of maltreatment, and neglect was the most common form of maltreatment across all disability types. A rela- tive-risk matrix for all types of maltreatment among

children with specific disabilities was developed. In 1 recent study, caregivers reported that 18.5% of children with autism had been physically abused and 16.6% had been sexually abused.14 Spencer et al15 concluded that children with disabling conditions are at increased risk of child abuse and neglect, although the type of maltreat- ment varies with the specific disabling condition.

LIMITATIONS OF CURRENT RESEARCH The prevalence of maltreatment of children with disabil- ities is difficult to calculate, because states do not use comparable definitions of child abuse and neglect. An- other major problem with the published literature is the variable definition of “disabilities.”4 The Centers for Dis- ease Control and Prevention describes developmental disabilities as a diverse group of severe chronic condi- tions that are attributable to mental and/or physical impairments and result in problems with major life ac- tivities such as language, mobility, learning, self-help, and independent living. The Americans With Disabilities Act16 defines “disability” as a physical or mental impair- ment that substantially limits 1 or more of the major life activities of an individual. This definition includes all types of disabilities, including physical disabilities, cog- nitive or learning disabilities, motor and sensory dys- functions, mental illness, or any other kind of physical, mental, or emotional impairment.17 Perrin18 reported that most childhood chronic health conditions do not cause disability. The Maternal and Child Health Bureau has defined children with special health care needs as “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional con- dition and who also require health and related services of a type or amount beyond that required by children generally.”19 The term “children with special health care needs” is less limiting than some other terms.20

Legal definitions do not always match clinical data. Child development evaluations do not always allow an immediate and precise diagnosis of extent or type of disability, and some studies rely on evaluations by un- trained observers. Therefore, evaluation of research ef- forts is 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.21

Another problem that has been cited in the literature is the lack of recognition and documentation of disabil- ities by CPS workers and their lack of training on eval- uating children with disabilities.4 In the study by Wes- tat,9 analyses were based on CPS workers’ opinions rather than data empirically derived from physicians or other professionals trained to diagnose disabilities. Bon- ner et al4 demonstrated that since 1982, correct and consistent use of a CPS-created system of collecting in- formation regarding disabilities in maltreated children

PEDIATRICS Volume 119, Number 5, May 2007 

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