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Abuse in Children with Disabilities

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Abuse in Children with Disabilities The Pediatric Perspective The CPC at the Children s Hospital at Montefiore Course Outline Definitions of maltreatment and ... – PowerPoint PPT presentation

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Title: Abuse in Children with Disabilities


1
Abuse in Children with Disabilities
  • The Pediatric Perspective

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The CPC at the Childrens Hospital at Montefiore
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Course Outline
  • Definitions of maltreatment and disability
  • Epidemiology
  • The medical providers 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 individuals 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
Lets 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

20
DISTRIBUTION OF DISABILITY TYPE
21
Sullivan and Knutson, 2000
  • 50,278 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
    sheriffs 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
PrevalenceLooking 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
All disabilities/All maltreatment 3.4 (31/9)
25
Relative Risk of Various Types of Maltreatment in
Children with Behavior Disorders
Neglect Physical Abuse Emotional Abuse Sexual Abuse
7.0 7.0 7.0 5.5
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
    (preschoolgtelementary), 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

29
ADDRESSING THE COMMON MISCONCEPTIONS
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 childs 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
  • --gt 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.

38
QUIZ QUESTION 1
39
THE ROLE OF THE MEDICAL PRACTITIONER
40
PEDIATRIC HEALTH PROVIDERS
  • GENERALIST PEDIATRICIANS
  • SPECIALIST PEDIATRICIANS
  • FAMILY PRACTITIONERS
  • NURSE PRACTITIONERS
  • PHYSICIAN ASSISTANTS

41
MODERN ROLE OF THE PEDIATRIC HEALTH PROVIDER
INCLUDES
  • Providing immunizations
  • Preventing injuries with anticipatory guidance
  • Discussing the childs 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 PROVIDERSIDENTIFICATION
  • 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 childs
    disability
  • Injuries must not be assumed to be related to the
    childs disability

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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

54
THE STORY OF M.F.
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HEALTH CARE PROVIDERSREPORTING
  • 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 PROVIDERSTREATMENT
  • Providers must treat injuries and infections
    appropriately
  • Assure that CPS is aware of the childs 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 PROVIDERSEDUCATION
  • 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 PROVIDERSPREVENTION
  • 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
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Crack Pipe
62
Family Violence
63
HEALTH CARE PROVIDERSPREVENTION
  • 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 PROVIDERSPREVENTION
  • 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 childs
    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 PROVIDERSPREVENTION
  • 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 PROVIDERSADVOCACY 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 PROVIDERSADVOCACY
  • 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

68
QUIZ QUESTION 2
69
SUMMARY
  • AMERICAN ACADEMY OF PEDIATRICS
  • AUGUST, 2001

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 familys 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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