The abuse of disabled children: a review of the literature

Sexual Abuse of Children With Disabilities: Key Lessons and Future Directions Based on a Scoping Review

In recent years there has been a growing public and professional interest in situations of risk, abuse, and exploitation of children with disabilities (CWDs). Despite the increasing awareness of CWDs experiencing child sexual abuse (CSA) at high rates, research in this area is still in its infancy. The current study seeks to identify, map, and thoroughly analyze the existing knowledge to better inform future research, policy, and practice. A scoping review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 35 articles addressing CSA among CWDs based on self-report surveys, official report data, and qualitative interviews. The findings addressed the phenomenon's epidemiology, disclosure, identification patterns, and consequences. Studies showed that CWDs experience CSA two to four times more often than children without disabilities and that they suffer longer and harsher abuse due to factors that complicate the identification of CSA of CWDs. This review highlights the diverse methodologies, producing a high variance in phenomenon rates, as well as unique methodological strategies for addressing challenges in CSA and disability research. Future research should focus on qualitative-retrospective studies of the perceptions of survivors and significant others in their lives (e.g., parents). Moreover, an intersectionality paradigm must be adopted in future studies to address the diverse contexts that construct the phenomenon (including sociocultural contexts). There is also a need to develop integrative interventions to allow higher accessibility of services, adaptive identification mechanisms, and more effective collaboration between professionals and CWDs.

Comorbidity and Overlaps between Autism Spectrum and Borderline Personality Disorder: State of the Art

Despite the relationship between Autism spectrum disorder (ASD) and personality disorders (PD) still being scarcely understood, recent investigations increased awareness about significant overlaps between some PD and autism spectrum conditions. In this framework, several studies suggested the presence of similarities between BPD and ASD symptoms and traits, based on the recent literature that increasingly reported increased comorbidity rates and significant symptomatologic overlaps between the two conditions. The aim of this review is to describe the available studies about the prevalence of the association between different forms of autism spectrum (full-fledged clinical conditions as well as subthreshold autistic traits) and BPD. Despite some controversial results and lack of homogeneity in the methods used for the diagnostic assessment, the reviewed literature highlighted how subjects with BPD reported higher scores on tests evaluating the presence of AT compared to a non-clinical population and hypothesized the presence of unrecognized ASD in some BPD patients or vice versa, while also describing a shared vulnerability towards traumatic events, and a greater risk of suicidality in BPD subjects with high autistic traits. However, the specific measure and nature of this association remain to be explored in more depth.

Sexual Crime Against Schoolchildren With Disabilities: A Nationwide Prospective Birth Cohort Study

Numerous studies have shown that the rate of sexual victimization against children with disabilities is higher than the rate for children without disabilities. The study focuses on examining sexual crime against children with disabilities and explaining differences in victimization to elucidate to what extent types of disability, family disadvantages, gender, high-risk behavior, and location influence adolescents' risk of sexual victimization. Data are based on a national study of reported sexual crime against children in Denmark aged between 7 and 18 years using total birth cohorts (N = 679,683). The statistical analysis is a discrete-time Cox model. An extended list of potential risk factors was included in the analysis to adjust for confounding. The potentially confounding risk factors were collected independently from various population-based registers, for example, employment statistics, housing statistics, education statistics, income compensation benefits, and population statistics (e.g., gender, age, location). Hospital records with information on types of disability based on the national inpatient register and national psychiatric register were collected independently of the collection of law enforcement records about reported sexual offenses under the Danish Central Crime Register. Among total birth cohorts, 8,039 persons or 1.18%. were victims of a reported sexual crime once or several times. Children with intellectual disabilities were more likely to be victimized of a reported sexual crime than non-disabled children were: attention-deficit/hyperactivity disorder (ADHD), odds ratio: 3.7 (3.5-3.9); mental retardation, odds ratio: 3.8 (3.6-4.0); and autism, odds ratio: 3.8 (3.6-4.0). This contrasts with children with speech disability, stuttering, and dyslexia who were less likely to be victimized when adjusted for family vulnerability and other confounding risk factors. Intellectual disability and family vulnerability, for example, parental substance abuse, parental violence, family separation, the child in care, and parental unemployment, indicate an increased risk of being a victim of a sexual crime, while speech disability seems to be ensuring protection.

Violence and Disability: Experiences and Perceptions of Victimization Among Deaf People

Research on the unique experiences of deaf people is rare, and limited information exists regarding the nature and extent of violence against this population. Existing scholarship highlights the increased vulnerabilities of deaf individuals; however, there remains a paucity of research that examines how deaf and hard of hearing individuals perceive their own victimization. Also lacking is research on the experiences of deaf individuals outside of the United States, where cultural norms and the status of the deaf may be quite different. In this article, we examine the relationship between violence and disability among 60 deaf people from developing countries. Each respondent is seeking legal asylum in the United States, and their asylum depositions provide the data for analysis. Thematic analyses reveal that deaf individuals experience abuse and violence within various social institutions and draw upon social perceptions of disability to explain their negative treatment. Notably, respondents cite their status as "devalued persons" as the driving factor behind institutional and interpersonal experiences of violence and, in some cases, respondents internalize this devalued status. The results suggest social conceptualizations of disability and deafness are important to consider in the context of violence and abuse.

Correlates of autistic traits among patients with borderline personality disorder

BACKGROUND

Despite discrete autism-related dimensions, such as deficits in communication, empathy and mentalizing are likely to affect the development of personality and despite they actually frequently occur in borderline patients, no research has so far investigated the relationship between autistic traits and Borderline Personality Disorder (BPD). The objective of this study is to investigate the clinical significance of autistic traits in subjects with BPD.

METHODS

The sample included 50 patients with a clinical diagnosis of BPD and 69 healthy controls. The Structured Clinical Interview for DSM-5 Clinician Version was used to establish the presence of comorbid mental disorders among BPD subjects and to confirm the absence of lifetime mental disorders in the control group. Participants were also asked to fill three self-report instruments: the Adult Autism Subthreshold Spectrum (AdAS Spectrum), the Autism Spectrum Quotient (AQ) and the Mood Spectrum Self-Report (MOODS-SR).

RESULTS

Patients with BPD reported higher autistic traits than healthy individuals. Moreover, autistic traits were shown to exert a significant impact on some clinical features and associated manifestation of BPD, such as suicidality and lifetime exposure to physical and/or sexual abuse.

CONCLUSIONS

Subthreshold autism spectrum may be relevant for subjects suffering from BPD and future research may further address clinical correlates of autistic traits among patients with this disorder.

Subdural hematomas: glutaric aciduria type 1 or abusive head trauma? A systematic review

Purpose

Glutaric aciduria type 1 (GA1) is a rare metabolic disorder of glutaryl-CoA-dehydrogenase enzyme deficiency. Children with GA1 are reported to be predisposed to subdural hematoma (SDH) development due to stretching of cortical veins secondary to cerebral atrophy and expansion of CSF spaces. Therefore, GA1 testing is part of the routine work-up in abusive head trauma (AHT). This systematic review addresses the coexistence of GA1 and SDH and the validity of GA1 in the differential diagnosis of AHT.

Methods

A systematic literature review, with language restriction, of papers published before 1 Jan 2015, was performed using Pubmed, PsychINFO, and Embase. Inclusion criteria were reported SDHs, hygromas or effusions in GA1 patients up to 18 years of age. Of 1599 publications, 20 publications were included for analysis.

Results

In total 20 cases, 14 boys and 6 girls, were included. In eight cases (40 %) a child abuse work-up was performed, which was negative in all cases. Clinical history revealed the presence of trauma in eight cases (40 %). In only one case neuroradiology revealed no abnormalities related to GA1 according to the authors, although on evaluation we could not exclude AHT.

Conclusion

From this systematic review we conclude that SDHs in 19/20 children with GA1 are accompanied by other brain abnormalities specific for GA1. One case with doubtful circumstances was the exception to this rule.

Evaluating children with fractures for child physical abuse

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

Clinical report—the pediatrician’s role in child maltreatment prevention

It is the pediatrician’s role to promote the child’s well-being and to help parents raise healthy, well-adjusted children. Pediatricians, therefore, can play an important role in the prevention of child maltreatment. Previous clinical reports and policy statements from the American Academy of Pediatrics have focused on improving the identification and management of child maltreatment. This clinical report outlines how the pediatrician can help to strengthen families and promote safe, stable, nurturing relationships with the aim of preventing maltreatment. After describing some of the triggers and factors that place children at risk for maltreatment, the report describes how pediatricians can identify family strengths, recognize risk factors, provide helpful guidance, and refer families to programs and other resources with the goal of strengthening families, preventing child maltreatment, and enhancing child development.

Situational analysis of poverty and violence among children and youth with disabilities in the Americas an agenda proposal

This article reviews the prevalence of poverty in Latin America and the Caribbean discussing the cycle and culture of poverty, their links to violence and maltreatment among disabled children and youth, from 1990 to 2006. There is a discussion of child maltreatment both of typical and disabled children taking into consideration the disabled child's unique needs, the impact on the family and society and the availability of supports and resources. Finally, an agenda is set forth to address poverty and violence, seeking to diminish the prevalence of maltreatment of all children, but especially children with disabilities. In addition, there is the hope of breaking the cycle of poverty and supporting disabled and marginalized individuals. This agenda speaks to the need for multidisciplinary collaboration as well as collaboration regionally and locally among governmental and non-governmental agencies, advocacy groups and the community at large.

Sexuality issues and gynecologic care of adolescents with developmental disabilities

All human beings are sexual from birth to death and all children and adolescents with or without disability or chronic illness must incorporate appropriate sexuality concepts into their processes of development from childhood to adolescence. This article considers sexuality issues and reproductive care of adolescents with developmental disabilities. Potential consequences of disability on sexuality are reviewed, including sexual abuse and sexual dysfunction. Comprehensive sexuality education is vital for normal growth and development of all youth including those with developmental disabilities.

On intimacy, sexual activities and exposure to sexual abuse among children and adolescents with mobility impairment

AIM

The aim was to describe experiences of intimacy and sexual activity and exposure to sexual abuse among children and adolescents with mobility impairment, and to relate these experiences to socio-demographic data, disability characteristics and well-being.

METHODS

This study included semi-structured interviews with 141 children and adolescents aged 7-18 years with mobility impairment. Interpersonal experiences of intimacy and sexuality, socio-demographic data, disability characteristics and well-being were registered.

RESULTS

About half of the children and adolescents in the study had been in a boy- or a girlfriend relationship, and about a fifth had an ongoing relationship. Of the adolescents, 15% had at least one experience of a sexual relationship. Whereas no particular sexual dysfunction was reported, 15% had concerns about their future sexual activities, presumably related to mobility impairment. A history of sexual abuse was reported by 7% in the age cohort of 13-18 years. The socio-demographic and disability-related features had a marginal influence on the experiences of intimacy and sexual activities.

CONCLUSION

Several aspects of sexual health are not fully realized for children and adolescents with impaired mobility, and there is a need for specialized sexual health care services to protect the sexual rights of this group.

Interviewing alleged victims with intellectual disabilities

BACKGROUND

When interviewing alleged victims of crime, it is important to obtain reports that are as accurate and complete as possible. This can be especially difficult when the alleged victims have intellectual disabilities (ID). This study explored how alleged victims with ID are interviewed by police officers in Sweden and how this may affect their ability to report information as accurately as possible.

METHODS

Twelve interviews with 11 alleged victims were selected from a larger sample. The complainants were interviewed when their chronological ages ranged from 6.1 to 22 years. A quantitative analysis examined the type of questions asked and the numbers of words and details they elicited in response.

RESULTS

Instead of open-ended questions, the interviewers relied heavily on focused questions, which are more likely to elicit inaccurate information. When given the opportunity, the witnesses were able to answer directive questions informatively.

CONCLUSIONS

Interviewers need special skills in order to interview alleged victims who have ID. In addition to using more open-ended questions, interviewers should speak in shorter sentences.

Abuse of the disabled child: a systematic review of population-based studies

OBJECTIVE

To ascertain the strength of the association between childhood disability and abuse and neglect.

METHODS

Systematic review of population-based studies published between 1966 and January 2006. Medline, Embase, Cinahl, Cochrane library, National Research Register, Social Sciences database and PsychInfo databases were searched for potentially relevant studies.

INCLUSION CRITERIA

population-based cohort, case-control or cross-sectional studies of children <18 years of age that reported empirical data on the association of abuse with disability. Risk estimates were expressed as odds ratios with 95% confidence intervals (CI) where possible. Meta-analysis was not undertaken because of heterogeneity of studies.

RESULTS

Four studies met the inclusion criteria. Two were longitudinal studies, one was a retrospective birth cohort and the remaining study was a cross-sectional survey. Types of disability studied varied widely as did methods used to ascertain abuse and neglect. Two studies accounted for potential confounding. Three studies reported an association between psychological and emotional disabilities and abuse. Two studies reported an association of learning disability with abuse. Only one study examined the association of physical disability (cerebral palsy) with abuse reporting an adjusted odds ratio for all forms of abuse of 1.79 (95% CI 0.96, 3.36) and for physical abuse of 3.00 (95% CI 1.29, 6.78).

CONCLUSIONS

The evidence base for an association of disability with abuse and neglect is weak. Psychological and emotional problems, and learning difficulties appear to be associated with abuse but this association might arise because these conditions share a common aetiological pathway with abuse. There is limited evidence that physical disability predisposes to abuse.

The effects of memory trace strength on eyewitness recall in children with and without intellectual disabilities

Children with mild moderate intellectual disabilities (ID) were compared with typically developing peers of the same chronological age (CA) on an eyewitness memory task in which memory trace strength was manipulated to examine whether increased memory trace strength would benefit those with ID more than those without ID. No evidence was found for this claim or for the notion that different mechanisms are implicated in memory processes for children with ID versus CA controls. Fuzzy-trace theory was also used to contrast question types that probed verbatim memory versus gist memory. Manipulations of trace strength, when used with immediate recall (to reduce the impact of decay), were predicted to improve verbatim memory more than gist memory. The results broadly supported the predictions. Performance was not improved in the stronger trace strength condition on measures of recall that tapped gist memory (e.g., open-ended recall), whereas performance was significantly better in the stronger trace strength condition on two of the three measures of recall that tapped verbatim memory (i.e., closed misleading questions, open-ended specific questions). Differences in performance between the groups were quite marked on several question types, supporting previous findings that those with ID have certain vulnerabilities as potential witnesses compared with peers of the same CA.

Injury prevention for children with disabilities

Little injury data exists for children who have disabilities. There is an urgent need to address injury prevention and to improve safety standards for this group. Understanding the epidemiology of injuries will allow clinicians to accurately advise patients and their families on individual risks and counsel them in steps to take to reduce those risks. Safety information must be tailored to consider each child's functional impairments. All children who have disabilities are at risk for maltreatment. Open discussion of this problem is warranted given the immensity of the problem. Identifying parental concerns and supporting parents in the use of respite resources are appropriate. For children who have problems in mobility, falls are the number one concern. Collaboration with reliable vendors and therapists that adhere to standards for safe seating is essential for reducing the risk of wheelchair tips and falls. In addition, therapists should be directed to provide mobility training for activities from safe transfers to street crossing in a community setting. Parents should be counseled to approach their child's injury risk based on the child's cognitive and behavioral level rather than their chronological level. Knowledge of the child's developmental quotient or intelligence quotient will also allow the clinician to accurately formulate an injury prevention plan. Many children will always need supervision for tasks that put them in situations of injury risk (i.e., swimming, street crossing, bathing). Sensorineural deficits such as blindness or deafness create significant alterations in negotiating the environment and an increased risk of injury. Awareness of the special needs for fire risk reduction and street safety are critical in this population. The collection of injury data is critical to define the scope of the problem and to influence changes in policy and the development of technical standards. Educational efforts focused on safety should include pediatricians, rehabilitative therapists, social workers, teachers, parents, and--most importantly--the empowerment of children as they age injury-free into adults. SUGGESTED STRATEGIES: A national injury surveillance system for children who have disabilities should be developed to identify injury risk factors for children with disabilities. Children with disabilities should be monitored as a separate risk group in data collection regarding injuries. Parents should be aware of the cognitive level of their child and its influence on their injury risk. Crash testing on passenger restraints should include crash dummies whose physical characteristics resemble those of children who have disabilities. Families should have an emergency evacuation plan with specific consideration of their disabled child in the event of an emergency. Risk of burns to insensate skin and risks of thermal and friction trauma should be discussed when appropriate. The fire department and the police department should be notified of the presence of a child who has a disability in the home. Parents must be aware of the risk of falls to children who are mobile but cognitively impaired and to those in wheelchairs regardless of cognitive ability. Hospitals must have Child Protective Services teams with specific training in abuse to children with disabilities. Discussion of maltreatment risk should be addressed during routine office visits and appropriate resources should be made available to provide support to families. Educational programs should be developed to alert providers to the risks of abuse of children who have disabilities.

Perinatal complications and child abuse in a poverty sample

OBJECTIVE

Perinatal medical illness has been associated with child maltreatment. Using a Child Protective Service (CPS) report as the defining event, this study explores to what extent perinatal morbidity is a risk factor for maltreatment.

METHOD

Medical charts of 206 children ages 0-3 years were reviewed. Data regarding birth history were collected and analyzed in three groups of children: children whose medical record indicated a report to CPS based on prenatal findings (Early Maternal Inadequacy group [EMI]), children whose medical record indicated a report to CPS based only on postnatal findings (Child Maltreatment group [CM]), and a control group without CPS report (NM).

RESULTS

Compared to the CM and the NM groups, children in the EMI group showed significantly lower birth weight and higher neonatal morbidity as measured by Apgar scores, frequency of oxygen requirement and intubation at birth, frequency of admission to Neonatal Intensive Care unit, and frequency of neonatal medical problems. There was no significant difference between the CM and the NM groups in birth weight, gestational age, and other measures of morbidity.

CONCLUSION

The results of the study suggest that perinatal complications are associated with prenatal maltreatment. Previously reported strong associations between neonatal morbidity and child abuse are more likely a result of antecedent prenatal maternal behaviors (early maternal inadequacy). Early maternal inadequacy, a clinically and demographically distinct phenomenon, is important due to serious health, development and financial implications and deserves further exploration.

Non-accidental injury or brittle bones

When a child presents with one or more unexplained fractures, non-accidental injury (NAI) should be considered in the differential diagnosis. This article reviews some of the other differential diagnoses, particularly osteogenesis imperfecta and the alleged "temporary brittle bone disease".

The sexual abuse of children with visual impairments

Approximately ten per cent of children in the United Kingdom are sexually abused and research suggests that handicapped children are similarly being sexually exploited. Replies to a questionnaire from special teachers indicated that more than half of them had had to deal with the suspected abuse of visually impaired children. There is need for further research; raised awareness on the part of professional staff; and the development of preventive strategies.