CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Maltreatment of Children
With Disabilities
Lori A. Legano, MD, FAAP,a Larry W. Desch, MD, FAAP,b Stephen A. Messner, MD, FAAP,c Sheila Idzerda, MD, FAAP,d
Emalee G. Flaherty, MD, FAAP,e COUNCIL ON CHILD ABUSE AND NEGLECT, COUNCIL ON CHILDREN WITH DISABILITIES

Over the past decade, there have been widespread efforts to raise awareness abstract
about maltreatment of children. Pediatric providers have received education a
Department of Pediatrics, Grossman School of Medicine, New York
about factors that make a child more vulnerable to being abused and University, New York, New York; bDepartment of Pediatrics, Chicago
Medical School, Rosalind Franklin University of Medicine and Science
neglected. The purpose of this clinical report is to ensure that children with and Advocate Children’s Hospital, Oak Lawn, Illinois; cStephanie V. Blank
disabilities are recognized as a population at increased risk for maltreatment. Center for Safe and Healthy Children, Children’s Healthcare of Atlanta,
This report updates the 2007 American Academy of Pediatrics clinical report Department of Pediatrics, Emory University School of Medicine, Atlanta,
Georgia; dBillings Clinic, Department of Medicine, University of
“Maltreatment of Children With Disabilities.” Since 2007, new information has Washington School of Medicine, Bozeman, Montana; and eDepartment
expanded our understanding of the incidence of abuse in this vulnerable of Pediatrics, Northwestern University Feinberg School of Medicine,
Chicago, Illinois
population. There is now information about which children with disabilities
are at greatest risk for maltreatment because not all disabling conditions Clinical reports from the American Academy of Pediatrics benefit from
expertise and resources of liaisons and internal (AAP) and external
confer the same risks of abuse or neglect. This updated report will serve as reviewers. However, clinical reports from the American Academy of
Pediatrics may not reflect the views of the liaisons or the
a resource for pediatricians and others who care for children with disabilities organizations or government agencies that they represent.
and offers guidance on risks for subpopulations of children with disabilities
The guidance in this report does not indicate an exclusive course of
who are at particularly high risk of abuse and neglect. The report will also treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
discuss ways in which the medical home can aid in early identification and
intervene when abuse and neglect are suspected. It will also describe All clinical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
community resources and preventive strategies that may reduce the risk of revised, or retired at or before that time.
abuse and neglect. This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have filed
conflict of interest statements with the American Academy of
Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
INTRODUCTION Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.

DOI: https://doi.org/10.1542/peds.2021-050920
The maltreatment of children, including those with disabilities, is
Address correspondence to Lori Legano, MD. Email: lori.legano@
a critical public health issue. For the purposes of this report, children nyulangone.org
with disabilities include the full spectrum of children and adolescents
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
with any significant impairment in any area of motor, sensory, social,
communicative, cognitive, or emotional functioning. Children and Copyright © 2021 by the American Academy of Pediatrics

youth with special health care needs is a broader group that shares
some of the same risks as children with disabilities. These children To cite: Legano LA, Desch LW, Messner SA, et al. AAP
have chronic medical issues that may cause impairment and, as a group, COUNCIL ON CHILD ABUSE AND NEGLECT, AAP COUNCIL ON
CHILDREN WITH DISABILITIES. Maltreatment of Children
require significantly more health care than typically developing
With Disabilities. Pediatrics. 2021;147(5):e2021050920
children.

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PEDIATRICS Volume 147, number 5, May 2021:e2021050920 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Current data on incidence and emotional disturbance, visual or A systematic review of violence
prevalence of maltreatment in hearing impairment, learning against children with disabilities
children with disabilities are limited disability, physical disability, behavior revealed that, overall, children with
by varying definitions of disability problem, or a few other chronic disabilities are more likely to be
and lack of uniform methods of medical conditions. It was believed victims of violence than their peers
classifying maltreatment. There is that children with such conditions are without disabilities. However, the
concern that the incidence of child undercounted because not every authors of that review reported
abuse and neglect is underreported in child received a clinical diagnostic limitations in the literature because of
part because many children with assessment when child maltreatment a lack of well-designed research
disabilities have communication was suspected. A recent study of the studies, with poor standards of
difficulties and cannot directly report data from the National Survey of measurement of disability and
problems.1,2 Nonetheless, children Child and Adolescent Well-Being II, violence and insufficient exploration
with disabilities and special health which included children older than 3 about whether violence preceded the
care needs are at increased risk of years, found that nearly one-half of disability.11
child maltreatment. This report children investigated by child
Child maltreatment may result in the
updates the previous clinical report protective services (CPS) were not
development of disabilities, which in
published in 2007, “Assessment of typically developing.5
turn can precipitate further abuse.
Maltreatment of Children With
Abusive head trauma, for example, is
Disabilities.”1 Child abuse and neglect is reported in
known to cause disabilities in
3% to 10% of the population with
The US Children’s Bureau reported children.14 The majority of survivors
disabilities.6–10 The rate of child
that an estimated 678 000 children of abusive head trauma have
abuse and neglect is at least 3 times
were determined to be victims of developmental delays, seizures,
higher in children with disabilities
abuse or neglect in 2018.3 Three- motor impairments, feeding
than in the typically developing
fifths (60.8%) of child victims difficulties, and later behavioral and
population.11 In a recent study by the
experienced neglect, 10.7% were educational dysfunction, with only
Federal Bureau of Justice Statistics,
physically abused, and 7.0% were 28% having no impairment.15 Vision
during the period from 2011 to
sexually abused; 15.5% of these loss can result from occipital cortical
2015, among all people older than 12
children suffered from 2 or more injury and optic nerve injury.16
years who had disabilities, people
maltreatment types.3 The 2010 Neglect is associated with short-term
between 12 and 15 years of age
reauthorization of the Child Abuse and long-term effects on children’s
had the highest rate of violent
Prevention and Treatment Act cognitive, socioemotional, and
victimization.8
(CAPTA) improved the data collection behavioral development.17,18 Neglect
from states on children with Using data from the National Child that occurs early in life can have more
disabilities by mandating that states Abuse and Neglect Data System, profound effects on development.
report the number of children Kistin et al12 evaluated the incidence Injury from abuse is augmented by
younger than 3 years who are
and timing of rereferral to CPS, the impact it has on the cortisol stress
involved in a substantiated case of
substantiated maltreatment, response and consequent physiologic
child maltreatment and are eligible to
determined foster care placement for impact. Adverse childhood
be referred for early intervention
children who had been reported to experiences, including child abuse
services and the number of children
CPS and had unsubstantiated neglect, and neglect, cause physiologic
who were actually referred for those
and compared typically developing disruptions that can persist into
services.4 It did not require collecting
children and children with adulthood and lead to lifelong poor
information regarding types of
disabilities. Children with disabilities physical and mental health.19
disabilities or the number of children
were re-referred to CPS more Exposure to traumatic events is
with disabilities who are older than 3
frequently, were found to have been associated with significant negative
years when they enter the child
abused more frequently, and were effects on long-term cognitive
welfare system.4
more often subsequently placed in development, such as IQ scores,
On the basis of national data from foster care.12 Once placed in foster language development, and academic
2015, child victims with a disability care, children with ID were more achievement.20 Specifically,
accounted for 14.1% of all victims of likely to experience placement witnessing intimate partner violence
abuse and neglect.4 In that report, instability13 and were more likely to in early childhood, particularly during
children with the following conditions have adoption disruption and less the first 2 years of life, is associated
were considered to have a disability: likely to be reunified with a parent or with decreased cognitive scores later
intellectual disability (ID), severe other family member.13 in childhood.21

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2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
FACTORS THAT INCREASE THE RISK OF caregiver of a child with FASD. children who have disabilities has
CHILD ABUSE AND NEGLECT Parents with ongoing substance use fortunately been diminishing, in
In general, the causes of abuse and disorders may also be less able to part because of legislative changes
neglect of children with disabilities handle their children’s challenging (eg, modifications of the Individuals
are the same as those for all children; behaviors and be more punitive to with Disabilities Education Act
however, several elements may their children.29 [Pub L No. 108-446 (2004)]), these
increase the risk of abuse for children practices are still sometimes used
Parenting a child with disabilities is in homes, schools, programs,
with disabilities. Children with
often challenging. Some children with nursing homes, group homes, and
chronic illnesses or disabilities
disabilities may not respond to other institutions. 32 Aversive
sometimes can place higher traditional means of reinforcement,
emotional, physical, economic, and techniques are procedures that use
and sometimes their behaviors, such painful or unpleasant stimuli (such
social demands on their families.22 as aggressiveness, noncompliance,
The financial stress of raising a child as biting the child, administering
and communication problems, can a noxious electric stimulus, or
with disabilities is often high, and this
become frustrating, thus increasing applying hot sauce to mucosal
contributes significantly to family
caregiver stress.30 These behavioral surfaces) to modify a behavior, and
stress.23,24 Other studies have found
challenges can increase the risk of these techniques are always
that families of children with
physical abuse by children’s unacceptable or inappropriate.
disabilities have significantly more caregivers.26
out-of-pocket costs for health care Restraints are physical measures
expenditures.24,25 Caregivers may feel Parents of a child with a disability (such as tie-downs or prolonged
more overwhelmed and unable to may also overestimate their child’s seclusion) used to prevent
cope with the care and supervision capabilities. In one study from the something physical from happening
responsibilities that are required.25 United States, parents of children or for punishment. Physical
Lack of respite or other breaks in with disabilities sometimes held restraints include forced holding,
child care responsibilities for unrealistically high expectations for a technique that has been
caregivers may contribute to an their children.9 Unrealistic repudiated as being harmful. 33
increased risk of abuse and neglect in expectations were also associated
children with disabilities. Neglect, the State laws are often unclear,
with a decreased degree of
most common form of child contradictory, and varied regarding
empathetic awareness of their child’s
maltreatment, is more prevalent in aversive and restraint techniques and
limitations. Parents of children with
children with disabilities than in intellectual or communication do not always consider the
children without disabilities.7 The problems may sometimes turn to techniques maltreatment.34
complex needs of children with inappropriate physical punishment Pediatricians and others can find
disabilities, in both special health care because of frustration about what additional information about the
and educational needs, may result in they perceive as stubbornness or problems occurring from the use of
the failure of the child to receive intentional failure to respond to aversive procedures or the use of
essential medications, therapies, and verbal guidance.31 Inappropriate restraints from the Web site Stop
appropriate educational expectations and ignorance of Hurting Kids (http://stophurtingkids.
placement.24,26 challenges a child with a disability com/resources/). Over the past 20
might face can be linked to a higher years, research has demonstrated the
A substance use disorder in the risk for maltreatment. Pediatric effectiveness of alternative measures,
mother is a risk factor for child providers can intervene by providing commonly called “positive behavioral
maltreatment27 and may be the cause reasonable expectations for parents supports,” to change behavior.9
of the child’s disability. Fetal alcohol regarding their children with Pediatricians are encouraged to
spectrum disorder (FASD) is a classic disabilities.9 Parents need advocate for this approach.
example. The use of alcohol or other information and support to Information about positive behavioral
substances during pregnancy can understand their child’s abilities and support guidelines is available from
cause a range of lifelong physical and challenges. They also need knowledge a US Department of Education-funded
behavioral disabilities and IDs.28 about proper strategies to use that program, the Technical Assistance
Children with FASD often have are appropriate for the disability- Center on Positive Behavioral
learning problems and speech and related problems and the Interventions and Supports, at www.
language issues and are typically developmental status of their child.25 pbis.org, as well as other national and
impulsive, lack focus, and have poor international programs. The
judgment. These problems can be Although the use of aversive American Academy of Child and
extremely frustrating for any procedures and restraints for Adolescent Psychiatry also provides

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PEDIATRICS Volume 147, number 5, May 2021 3
guidance on this subject (https:// participation).36 The most severely abused than those without
www.aacap.org). affected children are at a lower risk of a disability.41 Helton and Cross37 also
maltreatment than mobile, verbal found that there is an association
The presence of multiple caregivers
children who are still delayed, between disability and physical
can either increase or decrease the
especially those with cognitive abuse. Rather than comparing
risk of abuse of children with
disabilities.37 Children who are children on the basis of diagnosis,
disabilities. Children with disabilities
nonverbal or hearing impaired are they compared children on the basis
who require multiple caregivers or
more likely than others to experience of their level of functioning. The
providers may have contact with
neglect or sexual abuse.4 highest rates of physical abuse were
numerous individuals, thereby
in children with mild cognitive
increasing the opportunity for abuse. In an Australian study, researchers
disabilities and no motor disability.
However, advantages to having examined the relationship between
Paradoxically, children whose
a large number of caregivers are that different types of disabilities (eg,
disabilities are less severe are more
there are more individuals who may Down syndrome, autism) and the rate
likely to be the victims of physical
detect the injuries or signs of abuse, of substantiated maltreatment
abuse. These authors stated,
and the additional assistance may allegations.10 The authors found that
actually decrease the amount of children with ID, mental or behavioral “Conceptually, we can hypothesize
that children with minor impairment
stress placed on the primary problems, or conduct disorder had an
are at greater risk because they have
caregivers. Risk may be minimized by increased risk of an abuse allegation a complicated mix of dysfunctionality
careful screening and selection of and for a substantiated allegation. In and functionality. Their
caregivers, sporadic and unscheduled contrast, children with autism had dysfunctionality increases the
monitoring of care, and recognizing a lower risk than children with Down probability that they will act in a way
that elicits a negative reaction from
that any child may become a victim of syndrome, and those with birth
parents, while their functionality
child abuse and neglect. defects or cerebral palsy had the increases their parents’ expectations
same risk as children without of them and increase their ability to
Children with disabilities may be disability after adjusting for child, take actions that may frustrate their
unintentionally conditioned to family, and neighborhood risk factors. parents.”37
comply with authority, which could The type of abuse was not specified.
result in them failing to recognize Harsh discipline, whether physical or
abusive behaviors as maltreatment.35 In another study from South Carolina, verbal, can negatively affect children
Children with disabilities are often researchers examined the emotionally. Therefore, it is important
perceived as easy targets because relationship between autism to counsel parents of children with
their intellectual limitations may spectrum disorder (ASD) and ID and and without special needs about
prevent them from being able to child maltreatment.38 There were methods of discipline specifically as
discern the experience as abuse and higher odds of reported and they relate to the developmental level
their impaired communication substantiated maltreatment among of their child.42
abilities may prevent them from children with ASD only, ASD plus ID,
and ID only, compared with a control Neglect
disclosing abuse. Because some forms
of therapy may be painful (eg, group after controlling for In their study, Van Horne et al
injections or manipulation as part of sociodemographic factors. In a 2018 followed the risks of substantiated
physical therapy), a child may not be study from Tennessee, children with maltreatment in a cohort of children
able to differentiate appropriate pain ASD had more referrals to a child younger than 2 years with cleft lip
from inappropriate pain. abuse hotline than those without ASD, and palate, Down syndrome, and
although substantiation rates were spina bifida. In this study, the authors
similar between the 2 groups.39 In found that, although children with
ASSOCIATION BETWEEN DISABILITY a 2018 study using data from the Down syndrome had the same rate of
TYPE AND FORM OF ABUSE National Survey of Child and overall substantiated maltreatment as
Recent research has evaluated how Adolescent Well-Being II data, typically developing peers, children
differences in risk of abuse and children with multiple developmental with cleft lip and palate and spina
neglect correlated with the type and delays were more likely to have bifida had 2 times the rate of
severity of the child’s disability. The recurrence of child abuse reporting.40 maltreatment. However, the risk of
World Health Organization describes medical neglect was significantly
disabilities by the domains of Physical Abuse greater among all 3 birth defect
function that are affected (ie, Sullivan and Knutson found that groups than in the unaffected group
cognition, mobility, self-care, getting children with a disability were 3.79 of children. The medical complexity of
along, life activities, and times more likely to be physically these children may account for the

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4 FROM THE AMERICAN ACADEMY OF PEDIATRICS
increase in medical neglect.7 In child with IDs or communicative or in the prevention, identification, and
a follow-up study by Van Horne et motor disabilities.47 assessment of possible maltreatment
al43 on children aged 2 to 10 years It is also important to recognize that of children with disabilities.
with the same disabilities, children health care providers have been Recognizing that these children are at
with cleft lip and palate, Down implicated in sexual abuse of children a much higher risk is essential. It is
syndrome, and spina bifida all had with disabilities.48 Data about the important to assess whether
a higher rate of medical neglect incidence and prevalence of sexual immunizations and other well-child
compared with children who were abuse by health care providers are care are up to date and to ensure that
unaffected. In a study by McDonnell sparse and do not allow a thorough necessary appointments with
et al,38 children with ASD alone, ASD analysis of the incidence of the types specialists or for illness or injuries
plus ID, and ID alone were found to of abuse or the types of perpetrators are kept. Many children with
be at greater risk of physical neglect. because the terms “health care disabilities have a team of
Children with disabilities and provider” or “health care worker” professionals (including but not
unsubstantiated referrals for neglect encompass many subgroups, limited to teachers, paraprofessionals,
experienced future maltreatment including physicians, nurses, and and medical providers) who regularly
sooner and more often than other therapists. Given the increased interact with them and have direct
children.12 number of health care providers that knowledge about the limitations,
children with disabilities routinely abilities, and behaviors of that
encounter, it is essential that the individual child. By working closely
Sexual Abuse with these professionals, the
prohibition of sexual abuse and
In addition to physical abuse and exploitation be discussed and taught pediatrician can gather additional
neglect, children with disabilities are during the training of all health care insight into any concerns about
at an increased risk for being sexually providers. The 2011 American maltreatment and use this
abused.41,44 Caldas and Bensy44 Academy of Pediatrics (AAP) policy information to guide the medical
studied children aged 6 to 17 years in statement “Protecting Children From evaluation.
the school setting and examined types Sexual Abuse by Health Care
of abuse, profiles of the victims of Pediatricians and other health care
Providers” is an excellent resource to
abuse, and profiles of the abusers. providers play a key role in
help with this training.48
They found that children with evaluating and documenting medical
disabilities are at 3 times the risk of Emotional Abuse conditions that may or may not
sexual abuse compared with typically In a study from the United Kingdom, predispose children with disabilities
developing peers. The children with children with conduct disorder, to injury. For example, documenting
the greatest risk of abuse were nonconduct psychological disorders, the presence of, or a risk for,
children who had special education or speech and language difficulties osteopenia, is helpful in assessing
classroom supports. One-half of these were associated with a higher fractures that may occur later. Self-
abused children were victimized by likelihood of child protection injurious behaviors, such as
peers, and one-half were victimized registration for emotional abuse.49 headbanging and self-scratching, can
by school personnel. In a 2007 study Children with a psychiatric diagnosis elicit a CPS referral.53 Careful and
from Israel, researchers found that are at higher risk for psychological thorough documentation is often key
children with disabilities were more maltreatment and emotional abuse.50 in making a determination about
likely to suffer more severe forms of In a study from Turkey, children with whether an injury is consistent with
sexual abuse.45 attention-deficit/hyperactivity abuse or is a result of self-injurious
disorder (ADHD) were found to have behavior. Health care providers can
Multiple factors have been found to higher rates of emotional abuse than document abnormal physical
contribute to this increased rate of controls.51 In a retrospective study of examination findings, observed
sexual abuse in children with adults with and without ADHD, adults behaviors, and reported behaviors to
disabilities, including the increased with ADHD reported higher rates of establish the problem list for children
number of caregivers that children emotional abuse experienced as with disabilities. Many electronic
with disabilities encounter and children when compared with adults health records now have the
limited access to information and who did not have ADHD.52 capability to add digital photographs
training on personal safety and sexual and “for your information” flags and
abuse prevention.44,46 Parents alerts to the charts that can aid in
support education on human PEDIATRICIAN’S ROLE assessing future injuries or changes
sexuality but are uncertain of how Pediatricians and other health care in behavior based on preexisting
this topic should be presented to their providers need to be actively involved conditions. This documentation is

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PEDIATRICS Volume 147, number 5, May 2021 5
useful for collaboration with in- Pediatricians are responsible for the During each health supervision
hospital providers, such as transition of care to adult physicians encounter, pediatric providers can
emergency medicine providers, but may continue to manage patients address the medical, social, economic,
hospitalists, and critical care beyond their 18th birthday when behavioral, and psychological needs
providers who may also be part of the they are no longer minors. When of the child and the family. Proactively
system of care for children with patients enter adulthood, abuse addressing discipline concerns and
disabilities who are victims of abuse concerns are then referred to adult encouraging positive parenting are
and neglect. protective services. Pediatricians can especially needed in this
familiarize themselves with adult population.58 The AAP published
If abuse or neglect is suspected after
protective services in their state. a report strongly discouraging
a careful assessment, a report must
spanking and providing alternative
be made to the appropriate CPS
discipline practices.42 It is helpful to
agency.54 Collaboration with
recognize and support child and
a multidisciplinary child abuse team Prevention
family strengths at each encounter.55
or child abuse pediatrician can Support and assistance with The AAP provides several resources
provide both technical assistance in parenting skills are often needed by for positive parenting (eg, www.
the evaluation and guidance with the families, and the need is greater for healthychildren.org59; Bright Futures:
reporting process. Pediatricians may families with children and youth with Guidelines for Health Supervision of
also need to educate CPS about special health care needs or Infants, Children, and Adolescents,
medical findings to assist with the disabilities. Pediatricians, as trusted Fourth Edition60; and Connected
investigation by CPS. Careful family advisors, can acknowledge Kids61). Pediatricians can share other
consideration should be given family needs, provide encouragement, positive parenting resources with
regarding whether the evaluation is and address parents’ physical, social, families as well, such as the Centers
best completed in the outpatient and mental health needs.55 They can for Disease Control and Prevention’s
versus inpatient setting. There are present disability-specific injury Essentials for Parenting Toddlers and
advantages and disadvantages to prevention guidelines to help the Preschoolers (http://www.cdc.gov/
both; however, the safety of the child family minimize injury.56 The parents/essentials/overview.html).
needs to be kept at the forefront in availability of parent support groups,
the decision-making process. If there respite care, and home health All children, with or without
are reports of self-injurious behavior services should be explored, and disabilities, benefit from a medical
that have not previously been referrals may be made when home consisting of a health care
documented or observed by a third appropriate. Pediatricians can learn professional who is readily accessible
party, an inpatient evaluation should about services for parents of children to the family to answer questions,
be considered to observe the child’s with disabilities, such as respite and help coordinate care, and discuss
behaviors as part of the full medical medical waiver subsidies and concerns.62 A medical home may
evaluation. programs specific to each state and incorporate other professionals,
Appropriate medical treatment can be how to qualify for such funds.57 Table including social workers, to help with
provided for any identified injuries, 1 lists some resources for families of accessing resources. The medical
infections, or other conditions. Each children with disabilities. home can also collaborate with
case of abuse or neglect that is
clinically confirmed or strongly
TABLE 1 Resources for Families of Children With Disabilities
suspected requires
Resources
a multidisciplinary treatment plan.
Behavioral health referrals to Financial Supplemental Security Income (SSI), Special Supplemental Nutrition Program
clinicians experienced with caring for for Women, Infants, and Children (WIC), Medicaid waiver, therapist fees, Title
V maternal and child health services programs for children and youth with
children with disabilities needs to be special health care needs
considered as part of the treatment Respite or extended Respite centers, baby-sitting, after-school programs, emergency respite,
plan. Evidence-based trauma therapy care residential supports
is available for children with Specialized medical In-home nursing services, durable medical equipment
disabilities, although this type of needs
Emotional support Support groups, counseling services for families, family-to-family health
specific therapy may not be available information centers
in all communities (https://www. Educational support IFSPs, IEPs, special education teachers and paraprofessionals
nctsn.org/resources/facts-traumatic- Recreational Camps, after-school recreation, sports
stress-and-children-developmental- opportunities
disabilities). IEP, Individualized Education Program; IFSP, Individualized Family Service Plan.

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6 FROM THE AMERICAN ACADEMY OF PEDIATRICS
partners from other disciplines, such as to prevent a child from need.6 Pediatricians can advocate for
including education, child care, scratching at newly repaired the caregivers to receive financial
mental health, and faith-based lacerations, such restraints should be support to access services, such as
organizations. While working with as comfortable and as minimal as respite. Communication with schools
families of children with disabilities, possible and used for the shortest and other systems with which
health care providers can educate and time feasible. Pediatricians can also families interact is another avenue to
encourage them to work with be flexible about performing increase the awareness of the needs
community agencies that provide the procedures, such as delaying blood of children who have disabilities and/
resources and services they need to draws that are not essential. or special health care needs.
improve the child’s care and the
Pediatricians may also assist in
family’s coping. Child abuse As child advocates, pediatricians are
education about child abuse to peers,
prevention, including indicators of in an ideal position to influence
residents, medical students, and other
abuse, can be discussed with parents public policy by sharing information
health care students. All health care
and caregivers, especially those and giving educational presentations
professionals need adequate training
dealing with children with on child maltreatment and the needs
to monitor children with disabilities
disabilities, and taking into account of children with disabilities. There
for signs of abuse and neglect and to
the family’s language and culture.55 can be advocacy for training in
screen suspected victims of child
recognizing both abuse and findings
maltreatment for possible delays or
Education that mimic abuse for providers of
disabilities.63
children with disabilities.
In-service training for CPS and adult
Advocacy Pediatricians can advocate for state
protective service workers, law
policies that mandate CPS agencies to
enforcement professionals, health The pediatrician, in providing the gather disability information on child
care professionals, child care medical home and acting as the maltreatment cases. Pediatricians can
providers, early childhood educators, patient’s and family’s advocate, may emphasize the devastating costs of
teachers, and judges is crucial, and review care that is provided by child maltreatment to legislators,
protocols are necessary for the various agencies and resources. Much policy makers, and the public.
identification, reporting, and referral of this advocacy effort can be Pediatricians can advocate for state
of all cases of suspected child performed by coordinating efforts Medicaid programs to provide
maltreatment in all schools, and ensuring that recommendations prompt automatic Medicaid eligibility
programs, and institutional settings. are implemented.57 By providing at enrollment in foster care, including
Experts in either child maltreatment prevention-based continuity of care, kinship care. Pediatricians can also
or childhood disabilities can assist additional patient needs, such as advocate for health care not to be
with this educational endeavor. changes in services, can be disrupted if a child with disabilities is
General pediatricians can help local expediently identified and placed into Medicaid managed-care
school districts with training in resolved.
plans that do not have the child’s
positive behavioral interventions and
Pediatricians play an important existing specialists in network.
supports.32 Education on risk factors
advocacy role in their relationships Pediatricians can also advocate for
for maltreatment of children with
with various governmental and proper coverage in both private and
disabilities is important.
nongovernmental agencies. AAP public insurance plans. In the case of
Pediatricians can be important role chapters can also have an influential primary care, there should be a time-
models to parents, trainees, and role in these arenas. State, limited presumptive authorization
others. Pediatricians and other health educational, social, foster care, extended to a current primary care
care providers who provide care for financial, and health care systems provider for well visits and timely
children with disabilities can avoid often function in isolation from each immunization visits. Pediatricians can
using physical restraints during other, with little coordination or advocate that Medicaid programs pay
procedures for these children. Often, communication.35 Foster children for services necessary for the
taking the time to explain procedures with disabilities and their foster effective transition of care when there
in terms appropriate to parents, for example, often suffer must be a change in specialty
developmental level or other ways to from lack of adequate support providers. Pediatricians can also
prepare a child can make restraints systems.1 Community involvement advocate for screening procedures for
unnecessary except in situations can often lead to the development of potential employees in educational,
when children are dangerous to needed resources, including child recreational, and residential settings
themselves or others. Even when care and respite services for families to help ensure the safety of all
some types of restraints are needed, with a child with a special health care children in their care.32

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PEDIATRICS Volume 147, number 5, May 2021 7
SUMMARY how to respond to common National Child Traumatic Stress
Children with disabilities are developmentally based challenges Network. Available at: http://www.
a vulnerable population at increased for the child with a disability. nctsnet.org/trauma-types/
risk of child abuse and neglect and, 4. Refer families of children with pediatric-medical-traumatic-
therefore, merit special attention to disabilities to available community stress-toolkit-for-health-care-
reduce this risk. Children with milder resources and agencies that providers.
forms of disability are at higher risk provide necessary services Stop Hurting Kids: this Web site was
of abuse and neglect than more designed to aid children with created by the Alliance to Prevent
profoundly affected children. disabilities and their families. Restraint, Aversive Interventions,
5. Structure discussions about and Seclusion (APRAIS,) a coalition
Certain types of disabilities are of organizations and advocates
appropriate discipline within well-
associated with different forms of who dedicate their time and
child visits for the child with
abuse. Children with behavioral resources to ending restraint and
a disability. Parents may be
difficulties are at a greater risk for seclusion abuse in US schools.
uncertain as to how to deal with
physical abuse. Children who are Available at: http://
discipline, especially for children
nonverbal or hearing impaired are stophurtingkids.com/resources/.
who are verbal but
more likely to experience neglect or
developmentally delayed, so Hagan JF, Shaw JS, Duncan PM, eds.
sexual abuse. Children with multiple
provide guidance on positive Bright Futures: Guidelines for
developmental delays are more at
parenting. Consider referring these Health Supervision of Infants,
risk for recurrence of child abuse
families to specialists with Children, and Adolescents.
reporting. Conduct disorder,
expertise in parenting skills for 4th ed. Elk Grove Village, IL:
nonconduct psychological disorders,
children with disabilities. American Academy of Pediatrics;
speech and language difficulties, and
6. Be actively involved with both 2017. Available at: https://
ADHD are associated with emotional
educational and medical treatment brightfutures.aap.org/Pages/
abuse.
plans developed for children with default.aspx.
Addressing financial struggles, family disabilities and participate in American Academy of Pediatrics.
stress, and the long-term needs of collaborative team approaches. Connected Kids: Safe, Strong,
these children can reduce the risk of Secure. Available at: https:
7. Advocate at the state and local
child abuse and neglect. Pediatricians //www.aap.org/en-us/advocacy-
level for system changes that
are a unique resource to children and-policy/aap-health-initiatives/
support at-risk children and
with disabilities through the medical Pages/Connected-Kids.aspx.
those with disabilities and their
home model and in multidisciplinary
families.
teams.

LEAD AUTHORS
GUIDANCE FOR PEDIATRICIANS SUGGESTED RESOURCES Lori A. Legano, MD, FAAP
Larry W. Desch, MD, FAAP
1. Recognize signs and symptoms of A Call to Action: Ending Crimes of
Stephen A. Messner, MD, FAAP
child maltreatment in all children Violence against Children and Sheila Idzerda, MD, FAAP
and adolescents, including those Adults with Disabilities: this report Emalee G. Flaherty, MD, FAAP
with disabilities, and understand includes recommendations on
mandatory, state-specific reporting policy, surveillance systems and
requirements for child and adult data collection, violence
COUNCIL ON CHILD ABUSE AND NEGLECT,
protective services. prevention, intervention, and 2019–2020
2. Use each medical visit as an research needs. Available at:
Suzanne B. Haney, MD, FAAP, Chairperson
opportunity to assess family well- https://www.aucd.org/docs/ Andrew P. Sirotnak, MD, FAAP, Immediate
being. annual_mtg_2006/symp_ Past Chairperson
marge2003.pdf. Amy R. Gavril, MD, MSCI, FAAP
3. Understand that families of Rebecca Greenlee Girardet, MD, FAAP
children with disabilities benefit www.pbis.org: this Web-based
Amanda Bird Hoffert Gilmartin, MD, FAAP
from assistance in addressing their resource offers information about Sheila M. Idzerda, MD, FAAP
child’s abilities and needs. Provide programs supporting positive Antoinette Laskey, MD, MPH, MBA, FAAP
reasonable expectations for behavioral parenting for families Lori A. Legano, MD, FAAP
and other caregivers. Stephen A. Messner, MD, FAAP
parents regarding their children Bethany Anne Mohr, MD, FAAP
with disabilities and be prepared Toolkit for medical providers about Shalon Marie Nienow, MD, FAAP
to offer concrete suggestions about trauma-informed practice from the Norell Rosado, MD, FAAP

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8 FROM THE AMERICAN ACADEMY OF PEDIATRICS
FORMER COUNCIL ON CHILD ABUSE AND Rishi Agrawal, MD, MPH, FAAP Marshalyn Yeargin-Allsopp, MD, FAAP –
NEGLECT EXECUTIVE COMMITTEE MEMBERS Lynn F. Davidson, MD, FAAP Centers for Disease Control and Prevention
Kathryn A. Ellerbeck, MD, MPH, FAAP
Emalee G. Flaherty, MD, FAAP, Past Jessica E. A. Foster, MD, MPH, FAAP
Chairperson Ellen Fremion, MD, FAAP, FACP STAFF
Mary O’Connor Leppert, MD, FAAP Alexandra Kuznetsov
Barbara Saunders, DO, FAAP
LIAISONS
Christopher Stille, MD, MPH, FAAP
Heather C. Forkey, MD, FAAP – Council on Jilda Vargus-Adams, MD, MSc, FAAP
Foster Care, Adoption and Kinship Care Larry Yin, MD, MSPH, FAAP
Brooks Keeshin, MD, FAAP – American
Academy of Child and Adolescent Psychiatry
Jennifer Matjasko, PhD – Centers for Disease FORMER COUNCIL ON CHILDREN WITH
Control and Prevention ABBREVIATIONS
DISABILITIES EXECUTIVE COMMITTEE
Anish Raj, MD – Section on Pediatric Trainees AAP: American Academy of
MEMBERS
Elaine Stedt, MSW – Administration for
Children, Youth and Families, Office on Child Kenneth Norwood Jr, MD, FAAP, Immediate Pediatrics
Abuse and Neglect Past Chairperson ADHD: attention-deficit/hyperac-
tivity disorder
ASD: autism spectrum
STAFF LIAISONS disorder
Tammy Piazza Hurley Cara Coleman, JD, MPH – Family Voices CPS: child protective
Müge Chavdar, MPH Marie Y. Mann, MD, MPH, FAAP – Maternal services
and Child Health Bureau
FASD: fetal alcohol spectrum
Edwin Simpser, MD, FAAP – Section on Home
COUNCIL ON CHILDREN WITH DISABILITIES, disorder
Care
2019–2020 Jennifer Poon, MD, FAAP – Section on ID: intellectual disability
Dennis Z. Kuo, MD, MHS, FAAP, Chairperson Developmental and Behavioral Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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 Maltreatment of Children With Disabilities
Lori A. Legano, Larry W. Desch, Stephen A. Messner, Sheila Idzerda, Emalee G.
Flaherty, COUNCIL ON CHILD ABUSE AND NEGLECT and COUNCIL ON
CHILDREN WITH DISABILITIES
Pediatrics originally published online April 19, 2021;

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References This article cites 50 articles, 11 of which you can access for free at:
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021-050920#BIBL
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 Maltreatment of Children With Disabilities
Lori A. Legano, Larry W. Desch, Stephen A. Messner, Sheila Idzerda, Emalee G.
Flaherty, COUNCIL ON CHILD ABUSE AND NEGLECT and COUNCIL ON
CHILDREN WITH DISABILITIES
Pediatrics originally published online April 19, 2021;

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