Introduction

People with disabilities are often responded to as a homogenous group of people, with 'disabilities' being seen by some as a badge of biological inferiority (Goddard & Carew 1993). Safilios-Rothschild contends that people with a disability have been 'considered to be less intelligent, less able to make the "right" decisions, less "realistic", less logical, and less able to determine [their] own life' (1981, as cited in Goddard & Carew 1993, p.189).

The 'labels' used to define different types of disability have reinforced people's negative attitudes towards people with these disabilities. For example, 'epileptic' is used to refer to a person with epilepsy. The term serves to draw attention to the disability as if it were the individual's 'sole or salient feature' (Rubin & Quinn-Curran 1983).

Rubin and Quinn-Curran (1983) believe that making the disability synonymous with an individual's identity results in an individual who is both stigmatised and dehumanised. Biklen and Bogdan coined the term 'handicapism' to describe the 'theory and set of practices that promote unequal and unjust treatment of people because of apparent or assumed physical or mental disability' (1977, p.206, as cited in Rubin & Quinn-Curran 1983).

More recently, the term 'disability' has been replaced by 'those with disabilities', which Frost and Stein (1989, as cited in Goddard & Carew 1993) suggest has replaced the element of 'personal tragedy' with a term that reflects the element of 'social oppression' inherent in living with a disability.

This paper provides an overview of the available research evidence for a relationship between child maltreatment and disability. Specifically, it looks at research which investigates the relationship between children with disabilities, and parents with disabilities, and the potential for child maltreatment.

Because of the size of the literature, a review of the development of physical or intellectual disabilities in children as a result of maltreatment will be presented as part of a future Clearing House Issues Paper.

Theory and Debate

Historically, there have long been concerns regarding the consequences of people with an intellectual disability becoming parents (Dowdney & Skuse 1993). In the first half of this century the debate centred on whether intellectually disabled people should be allowed to bear children at all. The fear was that large numbers of intellectually disabled children would result, a view which lead to routine, compulsory sterilisation and/or institutionalisation as a consequence (Dowdney & Skuse 1993).

Parental Characteristics

That the vast majority of parents were seen to be capable of coping with difficult children and/or stressful situations without resorting to child maltreatment, led researchers to focus early investigations into the causes of child maltreatment on the identification of parental characteristics that might lead to maltreatment.

It was hypothesised that maltreating parents must lack some form of inner control or be afflicted with a major thought disorder which affected their recognition of the consequences of their actions (for example, Green 1978, as cited in Factor & Wolfe 1990). Certainly, the earliest investigations of the causes of child maltreatment reported that low perpetrator intelligence was related to child physical abuse (for example, Simpson 1967, as cited in Milner & Chilamkurti 1991).

However, by the 1970s the debate concerning parents with an intellectual disability had turned to the 'ethics, morality and legality of denying [adults with intellectual disabilities] the right to live within the community, to enjoy sexual expression and to raise children' (Dowdney & Skuse 1993, p.25). The questions then became: 'Can adults with intellectual disabilities parent competently?' and 'If they do not parent adequately, can they be taught to do so?'

In contrast, parents with physical disabilities received less attention, with physical disability being ignored rather than investigated as a potential contributor to maltreatment. Westbrook and Chinnery (1990) suggested that societal attitudes (and the lack of interest) towards mothers with a physical disability could be summed up by the following:

'There is almost no public image of disabled people as parents, and I do not know of a single book about being a disabled parent - although there are probably hundreds about having a disabled child' (Finger 1985, p.305, as cited in Westbrook & Chinnery 1990).

Child Characteristics

Attention to the child characteristics associated with child maltreatment developed in response to the recognition that some abused children were abused again in alternative care (National Research Council 1993). Attempts were made to determine which child characteristics might provoke anger from adults in 'at risk' and previously non-maltreating families.

One factor identified as having the potential to interfere with parent - child attachment and bonding, making a child more vulnerable to maltreatment, was children's intellectual or physical disability (Lynch & Roberts 1977; Oates et al. 1979).

However, theories of maltreatment that have focused primarily on child characteristics which may exacerbate the risk to the child of maltreatment have generated controversy, as such a focus may be perceived as victim blaming (Goddard & Carew 1993; National Research Council 1993).

Definitions

A number of different terms have been coined to describe physical or intellectual disability. The Australian Bureau of Statistics (ABS) base their research around the classification of disabling conditions into: impairment, disability and handicap.

The International Classification of Impairments, Disabilities and Handicaps (ICIDH) defines impairment as 'any loss or abnormality of psychological, physiological or anatomical structure or function' (ABS 1996, p.49). Examples of impairments are: loss of sight or a limb; disfigurement or deformity; mental retardation; speech disorders; psychological disorders; and lack of function of body organs. A disability can be defined as 'any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being' (ICIDH, as cited in ABS 1996, p.47).

Disabilities have been classified by the Australian Bureau of Statistics into a series of different impairments which have restricted a person's ability to perform an action, and which have lasted, or were likely to last, for at least six months. These include: loss of sight or hearing; speech difficulties; blackouts, fits or loss of consciousness; slowness of learning or understanding; incomplete use of limbs; treatment for nerves or an emotional condition; restriction in physical activities or work; disfigurement or deformity; head injury and/or brain damage; mental illness or a restrictive long-term medical condition.

Finally, disabilities may result in a handicap, that is, a limitation in performing certain tasks associated with daily living as a result of having a disability. The limitation could relate to self care, mobility, verbal communication, schooling or employment. Handicap is then further classified by severity: mild, moderate, severe and profound. Severity is determined by the amount of external support required by people with disabilities in order to function adequately (ABS 1996).

Ammerman (1990) noted that the key terms in both the disability and child maltreatment literature are often ill-defined in research studies and encompass a diversity of problems, thus limiting the comparability of studies. Further compounding the problem, few studies attempt to explicitly define and measure the severity of a disability.

Intellectual Disability

While the Australian Bureau of Statistics has attempted to explicitly define the range of physical disabilities, less attention has been paid to the classification of intellectual disabilities.

A large number of terms have been used to describe intellectual disability: 'mentally retarded', 'learning disabled' and 'mentally handicapped' - to list a few of the frequently used labels in the literature. As mentioned previously, there is a danger that people will be 'labelled' by the terms used to describe their condition and treated as a syndrome rather than as a complete person. Therefore, historically, as each popular descriptor has acquired a pejorative tone over time, it has been replaced (Dowdney & Skuse 1993).

Intellectual disability or 'mental retardation' is most commonly defined by an individual's score on standardised intelligence tests. On most standardised tests the average score is 100, with two-thirds of people achieving a score of between 85 and 115, which is considered within the 'normal' range.

Currently a borderline intellectual disability is defined as a score between 70 and 85; a mild intellectual disability, as a score between 55 and 70; a moderate disability, between 40 and 55; and a severe disability below 40 (ABS 1990, as cited in Department of Community Services 1992).

However, such scores are often supplemented by an assessment of 'deficits in adaptive behavior' aimed at determining the degree to which intellectually disabled people can maintain themselves in the community and abide by socially acceptable standards of behaviour (Grossman 1973, as cited in Dowdney & Skuse 1993).

Though 'learning disabled' has become the latest term in Australia to describe people suffering from some form of intellectual dysfunction, 'intellectual disability' will be used as the general term employed to describe such individuals in this paper, as it is the most common term currently used in the literature. Child maltreatment is defined as the sexual, physical or emotional abuse or neglect of a child.

Prevalence

According to the Australian Bureau of Statistics, approximately 29 per cent of the Australian population (five million people) had one or more impairments or long-term health conditions in 1993 (ABS 1996). Approximately 18 per cent of the Australian population (3.2 million) had one or more disabilities as a result of their condition, and 14 per cent of the population (2.5 million) were categorised as handicapped by their disability. Approximately 12 per cent of young people aged 0 - 24 years were reported to suffer from at least one impairment or long-term health condition. Of this latter group, 2 per cent were reported to be 'slow at learning or understanding', while 10 per cent had some form of physical impairment.

'Mental disorders' were reported in 0.3 per cent of children aged from 0 - 4 years, while approximately 10 per cent had some form of physically disabling condition. Of the latter, 6 per cent suffered from a respiratory disease; 0.6 per cent had Downs syndrome; 0.4 per cent were reported to have disorders of the nervous system, including cerebral palsy and epilepsy (ABS 1996).

These figures are closely allied to Garbarino's (1987) 'generally accepted estimates' of approximately 12 per cent of all children and young people being 'handicapped' or disabled. Unfortunately, there are currently no national Australian data published on the incidence of abused children with disabilities (The Wallis Group 1996). Nor are accurate data kept on the number of parents with a disability who maltreat their children.

Though very few investigations of child characteristics and maltreatment include disabled children as part of their samples (Ammerman 1990), of those that do, many have found that children with some form of disability are overrepresented in child maltreatment samples, with reported incidence levels ranging from 4 per cent to 70 per cent (Ammerman 1990).

For example, in the United Kingdom, Smith (1975, cited in Browne & Saqi 1988) reported that 13.5 per cent of his sample of physically abused children had some form of disability. The proportion of disabled and maltreated children in the Surrey area where the study was undertaken (14 per cent), was more than double the normal expectation (6.2 per cent) (Davis, Butler & Goldstein 1972, as cited in Browne & Saqi 1988).

Apart from the definitional issues which may hamper an accurate determination of the prevalence of maltreatment in disabled populations, conducting accurate epidemiological investigations may further be hampered by difficulties in identifying and substantiating assault. Children with a disability, particularly a severe disability, may be unable to understand or report the occurrence of physical or sexual assault (Ammerman 1990).

Parents with Physical Disabilities

Parents with physical disabilities are frequently described in the literature as being unable to fulfil normal social roles, such as parenting (Westbrook & Chinnery 1990). For example, Anthony (1970, as cited in Westbrook & Chinnery 1990) wrote that a disabled father tends to function as a 'non entity' or a 'younger sibling', while a disabled mother is perceived as a greater source of danger in the family because she is not able to 'perform her socio-emotional role of promoting family solidarity and security' (Westbrook & Chinnery 1990, p.19).

However, research investigating the association between parents with physical disabilities and child maltreatment is difficult to find. The available literature is concerned more with the ability to parent, rather than an investigation of the relationship, if any, between parental physical disability and child maltreatment. For example, Morris (1989, as cited in Westbrook & Chinnery 1990) studied 205 women with spinal injuries in the United Kingdom in order to determine their ability to parent before and after serious injury. Of the 86 women who suffered from quadriplegia or paraplegia, almost all who had children prior to their injury resumed the main caring role in the family.

Physical Abuse

Several researchers have reported that perpetrators of physical child abuse are more likely to have physical disabilities and/or other health problems (for example, Conger, Burgess & Barrett 1979, as cited in Milner & Chilamkurti 1991). Physically abusive parents were also reported as suffering from more physical 'handicaps' and health problems than matched comparison parents when completing the standardised Child Abuse Potential Inventory (Milner 1986, as cited in Milner & Chilamkurti 1991).

Parents with Intellectual Disabilities

As the rights of people who are intellectually disabled or learning disabled have become more firmly established in the last decade, together with the trend towards deinstitutionalisation and 'normalisation', increasing numbers of disabled adults are living outside of institutional settings forming relationships, marrying and having children (Seagull & Scheurer 1986).

It has been contended that scant attention has been paid to the ability of parents with an intellectually disability to adequately care for their children (Seagull & Scheurer 1986). Schilling et al. (1982, as cited in Seagull & Scheurer 1986) found only 14 studies published between 1947 and 1978 which dealt with the issue of child maltreatment and intellectually disabled parents. Of these, 13 studies found that the parents with an intellectually disability performed inadequately, or that intellectual disability was over represented among families investigated by child protection services - neglect being the most common form of maltreatment identified.

Using data from 1500 families seen by a multidisciplinary assessment team in Michigan (United States), Seagull and Scheurer (1986) followed up 20 families in which at least one parent had an intellectually disability (64 children), to determine the current living situation of the children one to seven years after the last therapeutic contact.

They found that all children in the sample had been classified as neglected, and in 45 per cent of families one or more children had been diagnosed with failure to thrive. In addition, there were some instances of physical, emotional and sexual abuse. At the time of follow-up, 11 of the 64 children had remained with their parents; six children had been voluntarily relinquished for adoption; the courts had terminated parental rights in 34 cases; nine children were residing in foster care; two children had been ordered into the custody of a non-disabled parent following divorce; and two children had died.

Seagull and Scheurer noted that no family in which a parent was significantly intellectually disabled achieved improvement in the care and protection of their children despite lengthy, elaborate treatment plans. They also concluded that, overall, because of the cognitive limitations of the parents with an intellectually disability, most were unable to benefit sufficiently from welfare services to enable them to retain the care of their children. However, it should be noted that the therapeutic program was not tailored to the needs of parents with an intellectual disability, but was a general program.

What was clear, however, was that families who retained custody and care of their children at follow-up had the presence of another adult who 'functioned more normally' and was able to provide extended daily support to the intellectually disabled parents and their children. The ameliorating role of adequate social support has generally been regarded as a protective factor against child maltreatment (for example, Garbarino 1977).

The United States National Research Council concluded that 'the operation of social relationships and social networks is a critical feature in the etiology of child maltreatment. Research that seeks to clarify the conditions under which social networks can serve as risk or protective factors in child maltreatment should be supported' (1993, p.141).

Allen (1995) sounded a cautionary note regarding the common finding that parents with an intellectual disability do not parent adequately. He contended that much of the research into parents with an intellectual disability has been skewed because of a reliance on parents who were already identified as needing assistance.

Neglect and Parental Characteristics

Polansky, Chalmers and Buttenweiser Williams (1981, as cited in National Research Council 1993) proposed that neglect, and chronic neglect in particular, could partly be explained by parental characteristics. While neglectful parents appear to be less depressed, anxious, angry or confused than physically abusive parents (Pianta, Egeland & Erickson 1989), such parents have often been described as 'childlike' or 'infantile', with low self esteem and an inability to plan important life choices, such as getting married or having children.

Many neglecting caregivers, particularly those identified in cases of chronic neglect, are described as 'low functioning' - that is, they have some type of mild intellectual disability, or a possible psychiatric condition (Nelson, Saunders & Landsman 1993; Tomison 1994).

Sexual Abuse and Parental Characteristics

As noted in Update on Child Sexual Abuse (Tomison 1995), though the literature on the personality characteristics of sex offenders is more extensive than any for other forms of maltreatment (National Research Council 1993), no consistent psychological profile of a typical offender has been constructed, nor has any one psychiatric disorder been identified across the majority of offenders.

Finkelhor (1984) noted a number of risk factors which may increase the likelihood of sexual offending; specifically, by overcoming internal inhibitions or external impediments to offending. These included: maternal illness or absence (providing greater opportunity for father - daughter incest); and child emotional deprivation, possibly leading to the child becoming more open to inappropriate 'affection' from an adult. Arousal and disinhibition in sexual abusers has sometimes been enhanced by intellectual disability or physiological abnormalities, but such abnormalities have not been substantiated as a major cause of sexual abuse (Araji & Finkelhor 1986).

Children with Disabilities

As mentioned above, attempts to identify child characteristics which may exacerbate the risk to a child of maltreatment have generated controversy on the basis that a focus on the maltreated child may be perceived as victim blaming (National Research Council 1993). Researchers have therefore attempted to delineate factors which may be causal from those which maintain or perpetuate maltreatment (Ammerman 1991; Drotar 1992). In general, however, little is known about the process by which child characteristics become risk factors and thus contribute to, or help maintain, abusive situations (National Research Council 1993).

Risk of Abuse

Goddard (1996) noted that just as it took many years to recognise the extent of child maltreatment, so has there been a similar reluctance to recognise the maltreatment of children with disabilities. Cohen and Warren (1990) noted that the number of publications on the physical abuse of children with a disability is minuscule in comparison with the overall literature on child maltreatment.

Why are children with a disability at greater risk of child maltreatment? Ammerman (1990) cites a number of factors which are hypothesised to increase the risk of child maltreatment for disabled children in general.

Disruptions in mother - child attachment

The formation of a good bond between a mother and infant may be disrupted by negative reactions to the birth of a disabled child. Such perceptions may continue over time. The bond may also be affected by: maternal depression; hostility towards the child; unresponsiveness or behavioural deficits in a child which a parent may perceive as disinterest; or unrealistic and inaccurate expectations regarding the child's development and abilities, which may result in parental disappointment and frustration.

Parental stress leading to physical abuse

Prolonged exposure to stress may lead to frustration which, in turn, may increase the risk of physical abuse. Moroney (1981, as cited in Kaufman et al. 1992) identified a number of factors related to increased stress in the parents of children with disabilities. These included: actual or perceived stigma; caregivers having to cope with extraordinary child care demands; decreased personal time for the caregiver; difficulties in managing child behaviour; and general feelings of pessimism about the future. The severity and social acceptability of the child's disability and the socio-economic level of the family also influence parental feelings towards the child (Mori 1983, as cited in Kaufman et al. 1992).

Other factors leading to abuse

Finally, because of the nature of their disability, disabled children may be vulnerable to maltreatment. Depending on the severity and type of disability they may not be able to defend themselves from assault and, if suffering from cognitive deficits, may be unable to report incidents of maltreatment. Children with a disability may also be vulnerable because of difficulties in distinguishing between accidental injuries that result from their impairment, and abuse-related injuries, thus hampering the detection of maltreatment when it is occurring.

Some authors have suggested, paradoxically, that the greater the severity of a child's disability, the more the risk of maltreatment is decreased (Martin & Beezley 1974; Steele 1980, both cited in Ammerman 1990). Based on their clinical experience, Martin and Beezley (1974, as cited in Ammerman 1990) contend that disabled children are not likely targets for maltreatment. They propose that a parent's frustration which may lead to abuse is mitigated if the parent perceives a disabled child's misbehaviour as clearly related to her/his disability, and not intentional.

Thus, Martin and Beezley suggest that children with conditions less evident to the parent, such as attention deficit hyperactivity disorder, may be more likely to be at risk of maltreatment. However, Rosenberg and Reppucci (1983) conclude that perceptions of intent appear to have little relation to the occurrence of child maltreatment, reporting that abusive parents were more likely to respond inappropriately to child behaviour problems which were resistant to intervention (such as crying), regardless of parental perceptions of the child's intent. In addition, while the rates of maltreatment in hyperactive children appear higher relative to the general population, the rate does not appear to be significantly different from other groups of psychiatrically disturbed children (Heffron et al. 1987, as cited in Ammerman 1990).

Research Evidence

Much of the literature on children with disabilities has focused on physical disability, or a holistic measure of 'disability'. Studies which do incorporate children with disabilities tend primarily to examine those with the more minor physical disabilities, rather than the more severe conditions. In addition, virtually no children with multiple disabilities are included in research studies.

Given that it is hypothesised that the 'form and magnitude of behavior problems exhibited by many multi-handicapped children [sic] (e.g. aggression, stereotypic behaviors) play an important role in the development of maltreatment, it is of paramount importance that such children be carefully evaluated before conclusions about their risk for abuse and neglect are reached (Ammerman et al. 1988)' (Ammerman 1990, p.214).

An exception has been a study by Ammerman et al. (1989) of children with multiple disabilities who were residents of a psychiatric hospital. They conducted a retrospective analysis of the charts of 150 children who, because of their extensive disabilities and often concomitant severe behavioural dysfunction, were likely to be at high risk of being maltreated.

It was found that 39 per cent of children (59 cases) had been victims of maltreatment, or that there was a strong likelihood of previous or current maltreatment. Physical abuse was the most common form of maltreatment, occurring in 69 per cent of the maltreated subgroup, followed by neglect (45 per cent) and sexual abuse (36 per cent). The severity of the maltreatment was particularly disturbing, with 66 per cent of the sexual abuse cases reported to involve penetration, and 40 per cent of the sexually abused children being assaulted by multiple perpetrators. In addition, 52 per cent of the maltreated subgroup had been subject to more than one form of maltreatment, many experienced concurrently.

In an attempt to respond to the recommendations of the United States National Research Council (1993) and others, Ammerman and Patz (1996) conducted a study which incorporated an ecological model of the causes of child maltreatment, enabling an examination of the influences of a number of potentially causative factors concurrently. Focusing on child physical abuse, they investigated the relative contributions of a number of child and maternal factors to child abuse potential in mothers of 84 children with disabilities and 48 without disabilities. The children with disabilities sample incorporated children with a wide range of disabilities and functional conditions; 'mental retardation' was frequently reported. Parents' intellectual functioning, global psychopathology and social resources were all measured.

Child measures included an assessment of potential stresses in the parent - child relationship, such as adaptability, hyperactivity and maternal attitude towards the child. These were hypothesised to be important factors which might increase the risk of maltreatment. Also included was a measure of care burden; that is, the level of 'burden' that a family may experience when raising a child with chronic illnesses or disabilities.

Ammerman and Patz found that the child characteristics as a whole made a significant contribution to the potential for child maltreatment above and beyond that explained by demographic and parental factors. However, the presence of a disability, in particular, was not a significant predictor of child abuse potential once other child and parent variables were taken into account.

The importance of this study is that it indicated that disability per se did not have a role in predicting child abuse potential independent of other child characteristics often associated with, but not unique to impairment (for example, hyperactivity, and difficulty adapting to changes in environment). Thus, the causative factors involved in the abuse of children with a disability may be similar to those factors operating in families where children are without disability. That is, the child characteristics that are often exhibited by children with a disability may be exhibited by all children, although they are disproportionately represented in populations of children with disabilities. Therefore, the findings of this study may be generalisable to the overall population, regardless of the presence of disability.

Australian research

There is a dearth of Australian research on the maltreatment of children with disabilities. A tracking study of suspected child maltreatment cases by Tomison (1994) provided a simple measure of the reported incidence of intellectual disability in a sample of suspected child maltreatment cases. In 32 of 293 cases (11 per cent) professionals reported that the subject child presented with some form of learning difficulty.

Classifying the cases by type of abuse suspected, it was found that learning difficulties were reported as a presenting problem in 12 per cent of sexual abuse cases (15 of 124), 7 per cent of physical abuse (four of 60), 19 per cent of emotional abuse cases (three of 16) and 9 per cent of neglect cases (eight of 93). Child physical or mental disability was reported as a presenting problem in four of the 293 cases (1.4 per cent).

In 1992, the New South Wales Department of Community Services released the results of an assessment of child protection cases involving children with a disability. A sample of 33 children with disabilities was identified from 449 registered child protection cases in nine western Sydney district centres. The 33 cases included seven cases of physical disability, two of psychiatric disability, 24 cases of developmental disability, and one of attention deficit disorder. The proportion of children with disabilities among the sample of child protection cases reflected the proportion of children with disabilities in the general population.

In 24 per cent of the sample of children with disabilities, the primary type of maltreatment was physical abuse (eight cases); an additional 24 per cent were classified as emotional abuse; 33 per cent were classified as neglect (11 cases); and 18 per cent (six cases) were classified as sexual abuse.

Mild to moderate developmental disabilities (based on ABS definitions of intellectual disability), which included intellectual impairment as a result of developmental delays, brain damage, degenerative disease and slow learning, were overrepresented in the sample of maltreated children with disabilities, supporting the view that such children are more at risk of maltreatment than children with a severe disability.

Neglect was reported more frequently, particularly in the 'developmental disabilities' subsample, where two-thirds of the children were neglected. Sexual abuse was reported less frequently than for the overall population of maltreated children; this may, in part, be accounted for by communication difficulties hampering children's disclosure. Children suffering from severe disability, in particular, may be unable to understand that they have been assaulted, or be unable to disclose the assault (Ammerman 1990).

Importantly, the majority of children were considered to be at risk partly, if not wholly, because of factors unrelated to their disability. One frequently reported risk factor was parental intellectual impairment. In one-third of families, and in half of the 'developmental disabilities' subsample, at least one parent had some degree of intellectual impairment.

Sexual abuse of children with disabilities

In recent years, concern over sexual abuse of children with a disability has grown considerably (Dowdney & Skuse 1993), yet research dedicated to this area remains scarce (Tharinger et al. 1990, as cited in Department of Community Services 1992). Children with disabilities are more likely to be included in studies of child protection where the focus is on physical abuse and neglect, or a generic 'abuse' variable. However, some studies have documented a history of sexual abuse experienced by parents with an intellectual disability in both childhood and adulthood (for example, Seagull & Scheurer 1986).

Garbarino (1987) stated that when children with disabilities are sexually abused, the perpetrators are often the people responsible for the most intimate aspects of their daily care. This was supported in a Canadian study of 215 cases of child sexual abuse involving children with disabilities. Sobsey (1994, as cited in Briggs 1995) reported that 67 per cent of offenders contacted their victims through special services for the disabled, with more than half of the offenders being paid staff or volunteers who provided a service relating to the victim's disability.

Sobsey concluded that, unlike children with no disability, much of the risk of sexual abuse for those with disabilities may result from their exposure to the support system. Thus, the risk of extra-familial sexual abuse is much greater for children with disabilities.

Garbarino suggested that children with disabilities may be particularly vulnerable to sexual assault because of institutional living, communication problems, their physical limitations, and a lack of general information and understanding of sexuality. This is especially the case at adolescence, when increased interest in sexual activity is normative. However, because of societal attitudes towards sexuality for people with disabilities, these young people may not be provided with adequate sex education. Thus, heightened interest in sexual activity, combined with a lack of understanding and knowledge, may result in young people with a disability being more vulnerable to becoming involved in sexually exploitative relationships.

Intellectual disability and maltreatment

Despite the small body of evidence, children with an intellectual disability have been found to be overrepresented in the population of maltreated children (Martin 1980).

Sandgrund, Gaines and Green (1974, as cited in Garbarino 1987) reported that serious 'mental retardation' was eight times more common in maltreated children than in similar, non-maltreated children. They also concluded that it was difficult to attribute the higher incidence of 'mental retardation' solely to the maltreatment suffered.

However, when Sandgrund et al. subsequently performed a multivariate analysis of risk factors associated with children, they failed to substantiate the findings outlined (Oates 1982). Other studies have also found no significant differences in the rate of maltreatment between intellectually disabled children and comparison groups (for example, Starr et al. 1984, as cited in Garbarino 1987).

Ammerman (1990) suggests that such discrepancies in incidence may result from: differences in the definition of what constitutes a disability; unclear or incomplete definitions of disabling conditions; a failure to differentiate between specific disabilities or the severity of disability; and the difficulties associated with identifying maltreatment in children with disabilities.

Child Deaths

From the child death inquiry literature, it is apparent that caregiver psychiatric illness or intellectual disability and/or child-related intellectual or physical disability, are cited as contributory factors in a number of cases (for example, Health and Community Services Victoria 1994; NSW Child Protection Council 1995; Department of Health (UK) 1991).

In New South Wales, around eight children are victims of fatal child abuse each year (NSW Child Protection Council 1995). The New South Wales Child Protection Council's Child Death Review Committee undertook an audit of all cases of child homicide which occurred in that State between 1989 and 1991 that were categorised or suspected of being fatal child abuse or neglect (NSW Child Protection Council 1995).

In a final sample of 22 cases, it was reported that 36 per cent of the child victims were described (either by the suspect and/or others) as being particularly difficult to care for either because they were ill (18 per cent), disobedient (9 per cent), intellectually or physically disabled (5 per cent), or exhibited 'difficult' behaviours (5 per cent). One suspect was described as having suffered brain damage which had lead to psychiatric disorder. However, no suspects were reported to have been suffering from a physical or intellectual disability (NSW Child Protection Council 1995).

Summarising research into child deaths in the United Kingdom, Greenland (1987) identified 18 factors (nine parent-related; nine child-related) which he believed could predict situations where a child was at high risk. A high risk situation was predicted if at least half of the 18 factors were identified in a family. 'Pregnant - postpartum - or chronic illness' was one of the parent related factors, while 'birth defect - chronic illness - developmental lag' was a child-related factor.

Prevention

It has been argued that society has undervalued and stigmatised people with disabilities which, in turn, has increased the potential for child maltreatment (Garbarino 1987; Goddard and Carew 1993). As noted in the Commonwealth Department of Health and Family Services' Action Plan For The Prevention of Abuse and Neglect of Children With Disabilities:

'... there are a number of myths in the community that undermine the dignity and rights of children with disabilities, which may contribute to either abuse or the acceptance of abuse, which need to be challenged through community education.' (The Wallis Group 1996, p.14)

Thus, a primary prevention goal might be to attempt to modify societal attitudes which discount the value of people with disabilities (Authier 1987). This may involve a campaign in which children with a disability are presented in a positive way, as children first, and having a disability second (The Wallis Group 1996). Similar media campaigns focusing on adults with disabilities have already been presented.

The Role of Schools

There are two major roles for schools in the prevention of maltreatment of children with disabilities. First, all children should be educated to encourage their understanding and acceptance of people with disabilities (The Wallis Group 1996). Second, all children, including those with disabilities, should be taught some form of protective behaviours or personal safety program.

However, sexual abuse prevention programs for children with disabilities often lag behind those designed for non-disabled children, despite the greater risk of sexual abuse for children with disabilities (Authier 1987; The Wallis Group 1996). Thus, the production of protective behaviour programs which specifically target children with a disability and which teach basic sex education, appropriate sexual behaviour and protective skills, should be prioritised (The Wallis Group 1996).

A number of Australian protective behaviours and personal safety programs have recently been devised to cater for the needs of children with disabilities. Professor Freda Briggs has written a book entitled 'Developing Personal Safety Skills in Children with Disabilities', which is designed to encourage teachers, parents and other caregivers to teach personal safety skills to children with disabilities. The book incorporates information about child protection and children with disabilities, along with a collection of curriculum ideas for teaching personal safety skills to children and young people with mild to severe disabilities in mainstreamed classes and special situations.

Peden and Russell-Brown (1996) developed the West Australian 'Feel Safe' protective behaviours program and associated materials, which are tailored for people with intellectual disabilities. The essential themes of the existing Protective Behaviours programs, 'We all have the right to feel safe all the time' and 'Nothing is so awful we can't talk with someone about it', were left unchanged in order to preserve the integrity of the program. However, the authors modified the program presentation and format to fit with the teaching principles of how learning occurs for people with intellectual disabilities.

In particular, the modifications took account of the need for repetition of important themes and concepts, and the need to ensure that any skills learnt could be generalised across a range of familiar and unfamiliar settings. The program was initially designed for use with adults who have intellectual disabilities, and limited evaluations have indicated that adult participants can retain key information at least three months after the program has been completed.

Participants have also demonstrated an ability to apply the strategies and concepts of protective behaviours. Peden and Russell-Brown report that they plan to develop a program for use with secondary school-age students with intellectual disabilities in the near future.

Family Support Services

Williams and Roper (1985, as cited in Goddard & Carew 1993) note that all parents require a break from their children at times. This is particularly so for families who care for a child with a disability. However, the extra care and attention that such children may require, often mean that these breaks are more difficult to achieve (Goddard & Carew 1993).

In 1987, Szwarc concluded that there were a significant number of Australian families who were desperately trying to continue to care for disabled children within the family home, in spite of the absence of respite care or other essential family support services. He noted that access to family support services may make the difference between a child with a disability being able to remain at home or having to be placed in permanent care (Szwarc 1987).

Hollingworth (1987) outlined the services she believed should be provided to support families who care for children with disabilities. These include: extensive home-based support (including assistance with daily household tasks); child care both for children with disabilities and any siblings; emergency or respite care; long-term care; appropriate educational services; financial support; parental counselling; and support for any other children in the family.

Hollingworth (1987) believed that services should be provided not only on the basis of the severity and type of disability, but should also take into account: family structure; cultural background; religious and ethical issues; individual personalities; the health of all family members; stability of the marital relationship; the family's financial situation; the adequacy of the family's home environment; and access to informal social support (such as family and friends). Similar family support services would appear appropriate for assisting families where the caregiver has a disability.

The crux of such support, though, appears to be the provision of adequate resources so that services can be provided for as long as families require them. However, the unavailability of family support services is a common theme in child welfare services in Australia and overseas (Goddard & Carew 1993; Nelson Saunders & Landsman 1993), and rationing of services a common result. Once existing services pull out, families who have been enabled to cope because of family support must often find other formal or informal means of support (Tomison 1994). If such support cannot be located, the outcome is likely to be less than optimal child care and child development, and possibly child maltreatment.

Multidisciplinary Approaches to Prevention

There is a need for a comprehensive, collaborative approach to the protection of children with disabilities, as recognised in the Department of Health and Family Services' Action Plan for children with disabilities (The Wallis Group 1996).

This Plan notes the need for the development of policies and protocols for the investigation and reporting of suspected maltreatment of children with disabilities. The importance of regular cross-program policy development and coordination between protective services and disability services, with a focus on prevention, is highlighted. Ensuring effective interagency cooperation between disability services and child protection units is seen as one way forward in effectively preventing the maltreatment of children in 'at risk' or abusing families, and/or protecting maltreated children from further harm (Authier 1987; The Wallis Group 1996).

The Plan recommends expanding communication and collaboration with mental health, education and other services which also have a role in the support of children and families where a child has a disability. It would seem a natural progression to expand this plan to incorporate services dealing with families where a parent has a disability. The Action Plan also recognises the need for the adequate training of child protection workers and other professionals involved in child and family support, to ensure they have the requisite knowledge and skills to work effectively with families where a parent and/or child has a disability.

Future Research Directions

There appears to have been a worldwide failure to fully delineate and investigate the effect of being a child with a disability, or being a parent with a disability, on the potential for child maltreatment. There is an obvious need to further investigate the specifics of these relationships, but how can this be achieved?

First, as concluded in the Department of Health and Family Services' Action Plan (The Wallis Group 1996), steps should be taken to ensure that appropriate, standard definitions of child maltreatment and disability are developed; further, that national statistics should be collected on the maltreatment of children with disabilities, with data analysis in child protection services extended to cover children with disabilities. These recommendations should be widened to incorporate the collection and analysis of data on the role of parents with disabilities in cases of child maltreatment.

As noted in previous Discussion Papers (for example, Tomison 1996), most Australian States and Territories utilise some form of risk assessment method in making child protection decisions, or at least workers are trained to look for risk factors in families. The issue, therefore, appears to be more a matter of using the resulting information effectively, rather than one of reorganising current child protection case practice. Similarly, existing services which cater for parents with disabilities should document cases where those disorders are occurring in families with dependent children. The availability of such data should not only lead to better practice, but should also facilitate the conduct of research into those issues.

Second, apart from problems in identifying the prevalence of children with disabilities, and in particular maltreated children, another significant issue has been determining the temporal relationship between the two phenomena; that is, ascertaining whether children with disabilities are more likely to be abused or whether children are more likely to become disabled through maltreatment (Groce 1988, as cited in National Research Council 1993).

Finally, there has been an overreliance on retrospective studies of children with disabilities and maltreatment, preventing an assessment of causal relationships. Further, the value of the existing body of research studies is restricted due to small sample sizes, a lack of appropriate comparison groups, and selection bias (Bertolli et al. 1992, as cited in National Research Council 1993).

If causal relationships are to be examined, prospective studies of the relationship between child maltreatment and types of disability should be conducted where possible. Garbarino (1987) proposes the development of a comparative study of child maltreatment involving samples of children whose disabilities are largely genetically determined; children whose disabilities could be caused by maltreatment; and children without disabilities. Despite the potential of such a study to disentangle the cause and effect relationships between disability and child maltreatment, Garbarino notes that the possibility of conducting such a study has yet to be explored.

Conclusion

Research on a possible association between child maltreatment and parental disability is virtually non-existent, resulting in continued relative ignorance with regard to the ways in which parental disability may contribute to child maltreatment.

In contrast, numerous studies have reported a higher rate of maltreatment for children with disabilities compared to those without, though the specifics of the relationship are yet to be determined (Ammerman 1990; Groce 1988, as cited in National Research Council 1993). Overall, as with investigations of other unitary factors and child maltreatment, it appears unlikely that a child disability in isolation causes child maltreatment. Rather, the 'presence of a handicap [sic] in combination with other factors, raises the overall risk for maltreatment' (Ammerman 1990, p.215).

References

• ABS (1996), Disability, Ageing and Carers, Australia: Disability and Disabling Conditions, Cat. No. 4433.0, AGPS, Canberra.
• Allen, J. (1995), 'Working with parents who have an intellectual disability and their young baby', Second National Family Preservation Conference: 'Protecting Children by Strengthening Families', conference papers, Canterbury Family Centre, Melbourne.
• Ammerman, R.T. (1990), 'Predisposing child factors', in R.T. Ammerman & M. Hersen (eds), Children at Risk: An Evaluation of Factors Contributing to Child Abuse and Neglect, Plenum Press, New York.
• Ammerman, R.T. (1991), 'The role of the child in physical abuse: a reappraisal', Violence and Victims, vol.6, no.2, pp.87 - 100.
• Ammerman, R.T., Hersen, M., Van Hasselt, V.B., McGonigle, J.J. & Lubetsky, M.J. (1989), 'Abuse and neglect in psychiatrically hospitalized multihandicapped children', Child Abuse and Neglect, vol.13, pp.335 - 343.
• Ammerman, R.T. & Patz, R.J. (1996), 'Determinants of child abuse potential: contribution of parent and child factors', Journal of Clinical Child Psychology, vol.25, no.3, pp.300 - 307.
• Araji, S. & Finkelhor, D. (1986), 'Abusers: a review of the research', in D. Finkelhor, A Sourcebook on Child Sexual Abuse, Sage Publications, Beverly Hills.
• Authier, K.J. (1987), 'The community basis for protecting handicapped children', in J. Garbarino, P.E. Brookhouser, K.J. Authier and associates (1987), Special Children Special Risks: The Maltreatment of Children with Disabilities, Aldine de Gruyter, New York.
• Briggs, F. (1995), Developing Personal Safety Skills in Children with Disabilities, Jessica Kingsley Publishers, London.
• Browne, K. & Saqi, S. (1988), 'Approaches to screening for child abuse and neglect', in K. Browne, C. Davies & P. Stratton (eds), Early Prediction and Prevention of Child Abuse, John Wiley & Sons, Chichester.
• Cohen, S. & Warren, R.D. (1990), 'The intersection of disability and child abuse in England and the United States', Child Welfare, vol.69, pp.253 - 262.
• Department of Community Services (1992), Child Protection and Children with Disabilities, Paper No.9, Child Abuse and Neglect Programme, NSW Department of Community Services, Sydney.
• Department of Health (UK) (1991), Child Abuse: A Study of Inquiry Reports 1980 - 1989, HMSO, London.
• Dowdney, L. & Skuse, D. (1993), 'Parenting provided by adults with mental retardation', Journal of Child Psychology and Psychiatry, vol.34, no.1, pp.25 - 47.
• Drotar, D. (1992), 'Prevention of neglect and nonorganic failure to thrive', in D.J. Willis, E.W. Holden & M. Rosenberg (eds), Prevention of Child Maltreatment: Developmental and Ecological Perspectives, John Wiley & Sons, New York, pp.115 - 149.
• Factor, D.C. & Wolfe, D.A. (1990), 'Parental psychopathology and high-risk children', in R.T. Ammerman & M. Hersen (eds), Children at Risk: An Evaluation of Factors Contributing to Child Abuse and Neglect, Plenum Press, New York.
• Finkelhor, D. (1984), Child Sexual Abuse: New Theory and Research, The Free Press, New York.
• Garbarino, J. (1977), 'The human ecology of child maltreatment: a conceptual model for research', Journal of Marriage and the Family, vol.39, pp.721 - 735.
• Garbarino, J. (1987), 'The abuse and neglect of special children: an introduction to the issues', in J. Garbarino, P.E. Brookhouser, K.J. Authier and associates (1987), Special Children Special Risks: The Maltreatment of Children with Disabilities, Aldine de Gruyter, New York.
• Goddard, C.R. (1996), Child Abuse and Child Protection: A Guide for Health, Education and Welfare Workers, Churchill Livingstone, Melbourne.
• Goddard, C.R. & Carew, R. (1993), Responding to Children: Child Welfare Practice, Longman Cheshire, Melbourne.
• Greenland, C. (1987), Preventing CAN Deaths: An International Study of Deaths Due to Child Abuse and Neglect, Tavistock, London.
• Health and Community Services Victoria (1994), Ministerial Inquiries into Child Deaths Annual Report 1992 - 93, L.V. North Government Printer, Melbourne.
• Hollingworth, J. (1987), 'Community support: children and disability', Australian Child and Family Welfare, vol.12, no.4, pp.19 - 21.
• Kaufman, K.L., Johnson, C.F., Cohn, D. & McCleery, J. (1992), 'Child maltreatment prevention in the health care and social service system', in D.J. Willis, E. W. Holden & M. Rosenberg (eds), Prevention of Child Maltreatment: Developmental and Ecological Perspectives, John Wiley & Sons, New York, pp.1 - 16.
• Lynch, M.A. & Roberts, J. (1977), 'Prediction of child abuse: signs of bonding failure in the maternity hospital', British Medical Journal, vol.1, pp.624 - 626.
• Martin, H.P. (1980), 'The consequences of being abused and neglected: how the child fares', in C.H. Kempe & R. Helfer (eds), The Battered Child, University of Chicago Press, Chicago.
• Milner, J.S. & Chilamkurti, C. (1991), 'Physical child abuse perpetrator characteristics: a review of the literature', Journal of Interpersonal Violence, vol.6, pp.345 - 366.
• National Research Council (1993), Understanding Child Abuse and Neglect, National Academy Press, Washington DC.
• Nelson, K. E., Saunders, E.J. & Landsman, M.J. (1993), 'Chronic child neglect in perspective, Social Work, vol.38, no.6, pp.661 - 671.
• NSW Child Protection Council (1995), Preventing Child Homicide: A Report from the New South Wales Child Protection Council's Child Death Review Committee, New South Wales Child Protection Council, Sydney.
• Oates, R.K. (1982), 'Risk factors associated with child abuse', in R.K. Oates (ed.), Child Abuse: A Community Concern, Butterworths, Sydney.
• Oates, R.K., Davis, A.A., Ryan, M.G & Stewart, L.F. (1979), 'Risk factors associated with child abuse', Child Abuse and Neglect, vol.3, no.2, pp.547 - 553.
• Peden, S. & Russell-Brown, A. (1996), '"Feel Safe": a disability services commission initiative', International Journal of Protective Behaviours, vol.1, September, pp.56 - 64.
• Pianta, R., Egeland, B. & Erickson, M.F. (1989), 'The antecedents of maltreatment: results of the Mother - Child Interaction Research Project', in D. Cicchetti & V. Carlson (eds), Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect, Cambridge University Press, Cambridge, MA.
• Rosenberg, M.S. & Reppucci, N.D. (1983), 'Abusive mothers: perceptions of their own and their children's behavior', Journal of Consulting and Clinical Psychology, vol.51, pp.674 - 682.
• Rubin, S. & Quinn-Curran, N. (1983), 'Lost, then found: parents' journey through the community service maze', in M. Seligman (ed.), The Family with a Handicapped Child: Understanding and Treatment, Grune & Stratton, New York.
• Seagull, E.A.W. & Scheurer, S.L. (1986), 'Neglected and abused children of mentally retarded parents', Child Abuse and Neglect, vol.10, pp.493 - 500.
• Szwarc, B. (1987), 'Child welfare and the disabled: is the battle for justice really being fought?', Australian Child and Family Welfare, vol.11, nos 2/3, pp.5 - 7
• The Wallis Group (1996), Action Plan for the Prevention of Abuse and Neglect of Children with Disabilities, Child Protection Policy Unit, Commonwealth Department of Health and Family Services, Canberra.
• Tomison, A. M. (1994), An Evaluation of Child Abuse Decision Making in the Barwon Region: A Report for the Victorian Health Promotion Foundation, Volumes I & II, Department of Social Work and Human Services, Monash University, Melbourne.
• Tomison, A.M. (1995), Update on Child Sexual Abuse, Issues Paper No.5, National Child Protection Clearing House, AIFS, Melbourne.
• Tomison, A.M. (1996), Child Maltreatment and Substance Abuse, Discussion Paper No.2, National Child Protection Clearing House, AIFS, Melbourne.
• Westbrook, M.T. & Chinnery, D.L. (1990), 'Negative attitudes toward physically disabled women having children: an additional handicap', Australian Social Work, vol.43, no.4, pp.17 - 22.