Clin Child Fam Psychol Rev (2009) 12:196–216
DOI 10.1007/s10567-009-0056-1
Violence Exposure Among Children with Disabilities
Patricia M. Sullivan
Published online: 11 June 2009

Springer Science+Business Media, LLC 2009
Abstract The focus of this paper is children with dis-
abilities exposed to a broad range of violence types
including child maltreatment, domestic violence, commu-
nity violence, and war and terrorism. Because disability
research must be interpreted on the basis of the definitional
paradigm employed, definitions of disability status and
current prevalence estimates as a function of a given par-
adigm are initially considered. These disability paradigms
include those used in federal, education, juvenile justice,
and health care arenas. Current prevalence estimates of
childhood disability in the U.S. are presented within the
frameworks of these varying definitions of disability status
in childhood. Summaries of research from 2000 to 2008 on
the four types of violence victimization addressed among
children with disabilities are presented and directions for
future research suggested.
Keywords Children
Disabilities
Violence

Child maltreatment
Introduction
‘‘Children’s talent to endure stems from their igno-
rance of alternatives’’
Maya Angelou (1969)
A computerized search was conducted to identify arti-
cles published between 2000 and 2008 addressing children
with disabilities exposed to child abuse and neglect,
P. M. Sullivan (&)
Center for the Study of Children’s Issues, Creighton University
School of Medicine, Omaha, NE, USA
e-mail: tsullivan@creighton.edu
123
domestic violence, community violence, and war and ter-
rorism. The articles reviewed were identified through
computerized searches (e.g., PsycInfo, CINAHLS, and
Medline), annotated bibliographies, and journals that typ-
ically publish articles on violence and abuse. There were
896 possible citations when queried for children as victims
of violence. These citations were cross-queried with gen-
eral and individual disability type and reviewed for con-
tent. A total of 50 articles were identified that addressed
children with disabilities exposed to some form of vio-
lence. Out of all articles reviewed, 30 were research studies
with original data and 20 were literature reviews.
Disability Definitions and Prevalence
A lack of data on the violence exposure and victimization
of children and youth with disabilities is universal across
many of the criminal justice and child maltreatment dat-
abases mandated, compiled, and maintained by the federal
government (Marge 2003; Sullivan 2003b, 2006). While
there are a variety of statutory authorities for the collection
of public datasets on the disability and victimization status
of children, this has created various repositories of dis-
ability data compiled with varying disability definition
algorithms. Importantly, data are not shared across these
repositories. The absence of a mandate and resources for a
comprehensive demographic study of childhood disability
across numerous health, education, social service, and
criminal justice agencies both perpetuates and compounds
the problem (Sullivan 2006). Any consideration of violence
exposure among children with disabilities must be prefaced
with an understanding of the definitional variability and
paucity of prevalence data that permeate the field of dis-
abilities in general.
Clin Child Fam Psychol Rev (2009) 12:196–216
Definitional Issues
The majority of data gathering of violence victimization
among people with disabilities is on individuals 15 years of
age and older (Sullivan 2003a). This exclusion of children
and youth with disabilities from infancy to 14 years is the
principal cause of the paucity of information regarding the
epidemiology of their violence exposure. This lack of data
is the result of disparate definitions of disabilities among
children and the failure to include children with disabilities
in existing violence-related surveillance systems.
There is currently no universal definition of what
constitutes a disability. There are various strategies for
operationally defining disability status that range from
medical models of physical deficits to inclusion models of
challenges and cultural differences (Sullivan 2003b,
2006). The operational definitions adopted by researchers,
medical providers, educators, the federal government, and
people with disabilities determine the available data on
children with disabilities (Sullivan 2003b). Although
many agencies collect data on disability status among
children, existing ‘‘data’’ are best described as estimates
because results vary as a function of the agency that is
collecting the disability data. These estimates also vary
according to how disability status is defined, the severity
of the disability, the age range employed in defining
disability status, and, importantly, the need for disability-
related services as a function of meeting the defined
disability criteria (Sullivan 2003b).
It is important to recognize that the term ‘‘develop-
mental disability’’ is not a generic term for all disabilities
that can occur and be identified among children. Not all
children with a disability have a developmental disability.
Developmental disabilities are severe, life-long disabilities
attributable to mental and/or physical impairments, man-
ifested before 22 years of age. Developmental disabilities
result in substantial limitations in three or more areas of
major life activities, namely, capacity for independent
living; economic self-sufficiency; learning, mobility;
receptive and expressive language; self-care; and/or self-
direction (U.S. Department of Health and Human Services
2008). Children with disabilities that may limit mobility
or learning, such as a specific learning disability or an
orthopedic impairment, are not always classified as hav-
ing a developmental disability. These ‘‘other’’ disabilities,
which can be limiting in the formative and school-age
years, may respond to rehabilitation with special educa-
tion and physical rehabilitation and not persist into
adulthood.
The epidemiology of childhood disabilities greatly
differs from that of adults. Children and adolescents face
numerous potentially disabling health conditions that
occur at a higher rate than found in adults (Perrin 2002).
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This is attributed to major new epidemics of obesity,
asthma, autistic spectrum disorders, Attention Deficit
Hyperactivity Disorder (ADD/HD), Type II diabetes, and
depression. Children and adolescents have different dis-
ability trajectories in chronicity and duration and have
fewer lasting disabilities than adults. Children may have
more than one disability. For example, children with
intellectual disabilities may also have visual, hearing, and
physical disabilities and are categorized as having multi-
ple disabilities for most research purposes. Simply trans-
posing surveillance methodologies to determine incidence
rates implemented with adults to disabled children is not
an effective strategy in conducting epidemiological
research.
Data on children with disabilities have been plagued
with inconsistent operational definitions, poorly defined
heterogeneous populations with disabilities, and question-
able validation procedures for determining disabilities
(Sullivan 2003b, 2006). Less visible groups of children
with disabilities including those in residential institutions
for the mentally retarded, schools for the deaf, the home-
less, and children of illegal aliens have either not been
counted or escaped detection. Definition standards of dis-
abilities among children and youth need to be established
that implement a common framework for understanding
disability statistics (Marge 2003). The World Health
Organization (WHO) International Classification of Func-
tioning, Disability and Health (ICF) is proposed as a tool to
describe human functioning and health and encompasses a
promising framework for this purpose in that it provides
uniform language for describing functioning, health, and
disability status that includes environmental contextual
factors, and the social impact of the disability (World
Health Organization 2002).
Prevalence Estimates
Prevalence estimates of children with disabilities in the
U.S. are dependent upon who is counting them and why
(Sullivan 2003b). Disability eligibility determinations are
necessary and are required for receiving services and
benefits in such areas as health and education, and quali-
fying for supplemental income from the federal govern-
ment. Prevalence rates and definitions vary with the
counter and the differing criteria used in determining dis-
ability status. Previous studies have compared estimates of
the prevalence of children with special health care needs
when different definitions and screening methods were
used. Not surprisingly, the studies have found a large
variance in the numbers of children with disabilities.
Health, education, juvenile justice, and federal paradigms
are briefly considered here.
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Children with Special Health Care Needs
The National Survey of Children with Special Health Care
Needs (NS-CSHCN) gathers national data on the total
number of children with special health care needs in the
U.S. This survey is sponsored by the Department of Health
and Human Services, (DHHS), the Health Resources and
Services Administration (HRSA), and the Maternal and
Child Health Bureau (MCHB) and conducted by the Cen-
ters for Disease Control and Prevention’s National Center
for Health Statistics. The 2005/2006 study estimated that
out of 73,680,291 children in the U.S., some 10,221,438
(13.87%) had special health care needs. The National
Mental Health Information Center estimated 2,900,593
children have special mental health care needs that include
emotional, behavioral, or developmental disorders that
require treatment (U.S. Department of Health and Human
Services 2008). Children with Special Health Care Needs
(CSHCN) are identified as a function of the need for public
assistance to pay for health care services, and accordingly,
their numbers are limited by socioeconomic parameters
that do not encompass children with disabilities from all
socioeconomic strata.
Children with Special Education Needs
The U.S. Department of Education, Office of Special
Education and Rehabilitation Services (OSERS) collects
and maintains data on the number of children and youth
ages 3–21 years served under the Individuals with Dis-
abilities Education Act (IDEA). Some 6.7 million children
and youth with disabilities received special education ser-
vices in the U.S. during the 2006–2007 school year (Planty
et al. 2008). These 6.7 million children represented some
13.5% of all children enrolled in public schools and
included children between the ages of 3 and 21 years
attending early education centers as well as primary and
secondary schools in all 50 states and within the Bureau of
Indian Affairs Schools (BIA). The majority of disabilities
identified in these children (70%) receiving special edu-
cation services were behavioral/emotional problems,
mental retardation, and learning disabilities. Speech and
language impairments comprised an additional one-fifth of
children with disabilities. The number of children served
has increased by almost 50% or 2.9 million children since
1976–1977, the first year data were compiled by OSERS on
children served in special education. This increase is
attributed to the growth in the number of children classified
with specific learning disabilities. Children with specific
learning disabilities account for more than half of all
children with disabilities served under the IDEA. A vul-
nerable population of infants and toddlers with disabilities
are not always identified for services. To address this
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Clin Child Fam Psychol Rev (2009) 12:196–216
problem, the Child Abuse and Prevention & Treatment Act
(CAPTA) was amended in 2003 to require that children
under the age of 3 who are victims of child abuse and/or
neglect be referred to IDEA services. In 2004, the IDEA
Improvement Act was enacted and mandates services for
maltreated infants and toddlers (Macomber 2006).
Children with Mental Health Needs
Children and youth with mental health problems often
intersect with the juvenile justice system. The report on the
Surgeon General’s Conference on Children’s Mental
Health held in 2000 indicated that one in ten children and
adolescents has a mental illness, and only one in five
receives some type of mental health services. Although the
number of children and youth who are placed in residential
treatment facilities (RTCs) is significant and accounts for a
large portion of health care dollars, their exact numbers are
estimates. More than 50,000 children with emotional and
behavioral problems have been placed in psychiatric set-
tings and residential group homes (U.S. Public Health
Service 2000). Children who are not identified or do not
receive services for their mental health problems through
intervention and treatment are likely to be incarcerated
(Burns et al. 2003).
Significant numbers of youth in the juvenile justice
system have education-related disabilities and are eligible
for special education and related services under the Federal
Individuals with Disabilities Act (IDEA) (Burrell and
Warboys 2000). Studies of incarcerated youth indicate that
as many as 70% have an identifiable disability (Leone et al.
1995). The two most common disabilities found in the
juvenile justice system are specific learning disability and
emotional disturbance. Large numbers of youth involved
with the juvenile justice system have education-related
disabilities, and as many as 20% of students with emotional
disabilities are arrested at least once before they leave
school (American Academy of Child and Adolescent
Psychiatry 2005). There is a significant gap in the research
literature addressing children and youth with disabilities
who are at risk of delinquency or involved in the juvenile
justice system (National Council on Disability 2003).
While each state provides statistics on the number of
children in their respective juvenile justice systems, sta-
tistics on disabled children are not consistently gathered or
reported, compromising the reliability of the records
maintained. There is a large discrepancy in the number of
youth with disabilities in the general population and those
who are incarcerated. In 2000, the Office of Special Edu-
cation Programs (OSEP) reported a 13% prevalence of
disabilities among 70 million school-age children com-
pared with an estimated 32% among an estimated 134,000
youth within the juvenile justice system.
Clin Child Fam Psychol Rev (2009) 12:196–216
In July 2004, a Congressional study identified over
15,000 youth, within a 6-month period, housed in juvenile
detention centers waiting for mental health services to
become available. Even more alarming was the finding that
two-thirds of these facilities housed youths as young as
7 years of age who had not been charged with a crime and
were awaiting mental health treatment (U.S. House of
Representatives Committee on Government Reform 2004).
The mental health services required by these children and
youth are substantial. In 2005, over $185 million in state,
local, and federal funds were expended on group home or
residential placements for children and youth (U.S.
Department of Health and Human Services 2006). Cur-
rently, no data are available on the number of children and
youth with behavior and emotional disabilities who are
exposed to or victimized by violence while incarcerated
and awaiting services addressing these disabilities. In
addition to Residential Treatment Centers, over 500,000
children and youth in the U.S. reside in some sort of foster
care placement. Many of these children have been victims
of some form of serious abuse or neglect and some 30%
have severe emotional, behavioral, or developmental
problems (American Academy of Child and Adolescent
Psychiatry 2005). Violence exposure and victimization
data are needed on children in out-of-home care facilities
and the prevalence and type of disabilities among these
children and youth.
Children Receiving Supplemental Social Security Benefits
For children and youth under 18 years of age, the Social
Security Administration defines a disability as ‘‘…a
medically determinable impairment or combination of
impairments that causes marked or severe functional
limitation(s), and can be expected to result in death, or
has lasted or can be expected to last for a continuous
period of not less than 12 months.’’ There were 1,078,977
children and youth 18 years of age or younger receiving
Supplemental Social Security (SSI) benefits in 2006
(Social Security Administration 2007). Data are needed
on the number of these children and youth with an
identified disability resulting from violence victimization
and/or exposure. Access to the Social Security database
will be necessary to identify violence linkages with dis-
ability determinations. Although unlikely, this would
result in a methodologically strong study that is urgently
needed and would guide public health policy and practice
for children and youth with disabilities.
Correlates of Disability Status
Several demographic correlates of disability status in
children have emerged irrespective of the prevalence
199
paradigm employed. Disabilities are more prevalent
among male children, school-age children, children from
low-income families, and children from single parent
homes (Stein and Silver 1999; Fujiura and Yamaki 2000;
Mudrick 2002). The higher prevalence of school-age
children with disabilities reflects that some disabilities,
primarily learning disabilities and behavior disorders, are
first identified in the early school years. Families receiv-
ing public assistance are twice as likely to have a child
with a disability as higher income families (Lee et al.
2002). The relationship between ethnicity and disability
status is not clearly understood. Although higher rates of
disabilities among African American and Hispanic chil-
dren have been reported in the U.S. Census data (McNeil
2001), these findings were not replicated in a smaller
study when family structure and income were controlled
(Fujiura and Yamaki 2000). While the links between
disability status and gender, poverty, and family structure
are consistently delineated, the association between dis-
ability and ethnicity is variable depending on the study.
Data compiled from the Twenty-fifth Annual Report to
Congress on the Implementation of the Individual with
Disabilities Act (U.S. Department of Education 2005)
indicate the following ethnic percentages among children
with disabilities: Caucasians, 63.8%; African Americans,
17.1%; Hispanics, 15.2%; Asian/Pacific Islanders, 2.7%;
and American Indian/Alaskan Native, 1.2%. There is
variability in the type of disability across ethnic groups.
Specific Learning Disorder is the most prevalent disability
among all 5 ethnicities. Caucasians and Asian/Pacific
Islander children have the largest percentage of Speech
Language Impairments. Mental Retardation and Behavior
Disorders are most prevalent among African American
children. American Indian/Native Alaskan children have
more Developmental Delays than other ethnic groups.
Finally, Autism and Hearing Impairments are most pre-
valent among Asian children. The other specific disabili-
ties (multiple disabilities, orthopedic impairments, other
health impairments, visual impairments, deafblindness,
and traumatic brain injury) are comparable across all
ethnic groups. There are essentially twice the numbers of
disabilities among males than females irrespective of
ethnic group.
The definitional paradigms and prevalence estimates
presented here attest to the presence of available and suf-
ficient numbers of children with disabilities to warrant their
study. Although the multiplicity of definitional frameworks
impedes research, they are not insurmountable. Valid and
reliable research can be undertaken with children with
disabilities by choosing a paradigm and adhering to it
throughout a research protocol. Simply stating that children
with disabilities cannot be studied because of definitional
vagaries is no longer tenable.
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Child Abuse and Neglect
The majority of the violence-related research that includes
children with disabilities has been done in the area of child
maltreatment. Since the early 1990s, a substantial number
of studies have been completed in medical, social service,
law enforcement, and school settings. These will be dis-
cussed by study setting.
Child Abuse and Neglect Studies in Medical Settings
Early work on the prevalence of abuse and neglect among
samples of disabled children referred to medical treatment
centers was criticized for subject selection biases given that
these settings inherently have abused individuals seeking
treatment. Furthermore, they are prone to miss large
cohorts of neglected children who are not typically referred
for treatment in medical centers. In a sample of 482 con-
secutively referred maltreated children with disabilities in a
hospital setting, Sullivan et al. (1991) found that sexual
abuse or a combination of sexual and physical abuse per-
petrated by family members were the most common forms
of maltreatment endured by the referred children. The
subjects represented a limited set of disabilities, namely,
communication disorders including speech and/or hearing
impairments, learning disabilities, and cleft lip and/or
palate. Males were more likely to be victims of sexual
abuse than other types of maltreatment. Placement in a
residential school was identified as a major risk factor for
sexual abuse among deaf and hard-of-hearing children.
Similar results were obtained in a 5-year retrospective
study of 4,340 child patients in a pediatric hospital wherein
the majority (68%) were victims of sexual abuse and 32%
were victims of physical abuse perpetrated by family
members (Willging et al. 1992). Other work in nonmedical
settings in Great Britain (Westcott 1991), Australia (Turk
and Brown 1992), and Canada (Sobsey and Doe 1991) also
identified sexual abuse as the most prevalent form of
maltreatment among children with disabilities. This con-
trasts with nondisabled children in national incidence
studies of child abuse and neglect (NIS) in the U.S.
wherein the most prevalent form of maltreatment is neglect
(NIS-1 1981; NIS-2 1988; NIS-3 1996). Although it seems
likely this type of maltreatment discrepancy between
children with and without disabilities reflects a subject
selection bias in the medical study samples, a longitudinal
prospective study of 644 families using social service
records and self-report found that children with disabilities
requiring special education were at increased risk for sex-
ual abuse (Brown et al. 1998).
In Norway, questionnaires were sent to 26 pediatric
hospitals requesting information on the proportion of dis-
abled children receiving medical attention for suspected
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Clin Child Fam Psychol Rev (2009) 12:196–216
sexual abuse as well as the demographic characteristics of
those children including disability type, age, gender, and
the determination of the abuse allegations (Kvam 2000).
There were 1,293 children ranging in age from infancy to
16 years seen in these hospitals because of suspected
sexual assault between 1994 and 1996. Data obtained
through medical record reviews identified 54 girls and 29
boys with disabilities accounting for 6.4% of the total
sample. Identified disabilities included mental retardation,
cerebral palsy/physical disabilities, and deafness. As mea-
sured by a researcher-constructed method to discern the
‘‘probability of assault,’’ the children with disabilities were
at increased risk for sexual abuse and this risk increased
with the severity of the disability. Children with behavior
disorders, mental retardation, and physical disabilities were
the most susceptible to sexual abuse and boys seemed to be
more susceptible than girls. These results support earlier
findings that sexual abuse is a major form of maltreatment
found among disabled children accessing health care
services.
Giardino et al. (2003) examined medical records of
consecutive referrals to a health care team in a hospital
setting conducting medical evaluations for suspected child
maltreatment in children with special health care needs.
Medical records of the evaluations completed on 60 chil-
dren ranging in age from 3 to 16 years between January
1996 and August 1998 were reviewed. Identified disabili-
ties included ADHD, autism, blindness, cerebral palsy,
developmental delay, hearing impairment, mental retarda-
tion, and speech/language delays. Child Protective Services
and physicians were the primary referral sources. Records
of the team evaluations indicated that 31% of the children
were likely victims of maltreatment, the majority of it
sexual. These authors also documented the low reim-
bursement rate (14%) for these specialized evaluation
services of children with disabilities. Given their increased
risk for maltreatment, this low reimbursement rate is
unacceptable and is a deterrent to medical centers offering
these services. These fiscal barriers to receiving reimbursed
specialized evaluations for children with disabilities to
determine maltreatment have an unintended consequence.
They quite likely facilitate its very existence by preventing
the discovery of maltreatment by specialized teams of
professionals with expertise in interviewing children with
disabilities.
Sullivan and Knutson (1998a) evaluated the association
between disabilities and maltreatment using a hospital-
based population that permitted diagnoses of disabilities
from medical records. Additionally, using Child Protective
Service (CPS), foster care, and law enforcement records to
obtain evidence of maltreatment, the study determined the
presence of both intrafamilial (i.e., immediate and extended
family) and extrafamilial (i.e., nonfamily) maltreatment.
Clin Child Fam Psychol Rev (2009) 12:196–216
Based on a merger of 39,252 hospital records of all child
patients seen dating from 1982 to 1992, a 15% prevalence
rate of maltreatment was found and some 64% of the chil-
dren had an identified disability. This merger was replicated
in 2000 and merged 172,332 patients seen between 1982
with updated maltreatment databases from CPS, foster care,
and law enforcement agencies. A 16% rate of maltreatment
was identified and 66% of the children had a diagnosed
disability in the same hospital population. Thus, both the
maltreatment and disability rates among the hospital child
and adolescent patients were consistent over time. The
hospital files of a sample of 3001 maltreated children and
880 nonabused control children were reviewed for disabil-
ity, maltreatment, and perpetrator characteristics. Behavior
disorders, speech/language disabilities, learning disabilities,
mental retardation, and hearing impairment were the most
common disabilities. The most prevalent form of mal-
treatment was neglect followed by physical and sexual
abuse. Gender was significantly related to sexual abuse with
more girls than boys identified as victims. There were no
gender differences for neglect or physical abuse. Although
this research provided strong support for a link between
disabilities and maltreatment, the use of a hospital-based
sample limited the generalizability of that research to hos-
pital settings.
The Sullivan and Knutson (1998a) research also iden-
tified a cohort of youth in a residential placement among
the hospital patient database. The youth at Father Flana-
gan’s Boys Home (Boys Town) receive medical services
through the Boys Town National Research Hospital. This
afforded an opportunity to compare the disability and
maltreatment characteristics of children and youth living at
home to those in residential care. The findings showed that
64% of the youth who resided at home had a diagnosed
disability compared to 95% of the youth residing at Boys
Town. Behavior disorders were the most prevalent dis-
ability for both groups of youth. Only 21.6% of the youth
living at home had a diagnosis of some type of behavior
disorder compared to 80% of youth residing at Boys Town.
Speech and language, mental retardation, hearing impair-
ment, learning disorders, and health impairments were
found to be more prevalent in youth residing at home.
Other disabilities including autism, cerebral palsy, ortho-
pedic impairments, and Attention Deficit Disorder were
slightly more prevalent in the residential sample. Multiple
forms of maltreatment were more prevalent than any one
type of maltreatment in both samples with almost half of
youth residing at home and two-thirds of Boys Town youth
experiencing more than one type of maltreatment. With the
youth experiencing only one form of maltreatment, neglect
was the most common with 27.1% of youth who resided at
home being neglected compared to 23.1% of the Boys
Town youth. Physical abuse was the second most prevalent
201
form of maltreatment followed by sexual abuse and emo-
tional abuse. Emotional maltreatment alone was rarely
recorded in either sample, but was coincidental with other
forms of abuse. These results suggest that there are dif-
ferential patterns in both maltreatment and disability status
as a function of type of placement. The findings need to be
replicated in other samples of children and youth in resi-
dential treatment centers and group homes.
A school-based epidemiological study conducted by
Sullivan and Knutson (2000a) utilized archival categorical
data from a total population of 40,211 children enrolled in
the Omaha Public Schools during the 1995–1996 school
years and merged it with the Nebraska Central Registry,
Nebraska Foster Care Review Board, and the Omaha police
databases. This research was a conceptual replication of the
hospital study to examine differences in the epidemiology
of maltreated children with disabilities. Two control groups
(disabled and nondisabled) were identified without records
of maltreatment. An overall 11% prevalence rate of mal-
treatment for this school-based sample was identified.
Among the 4,503 maltreated children, 22% had an identi-
fied disability for which they were receiving special edu-
cation services in school. Among the children without an
identified disability, 9% were victims of maltreatment. In
contrast, 31% of the children with an identified disability
had records of maltreatment in either social service or
police records. The identified disabilities among the mal-
treated children were as follows: behavior disorders,
37.4%; mental retardation, 24.1%; learning disabled,
16.4%; health related, 11.2%; speech language, 6.5%;
hearing impairment, 1.3%; multiple disabilities, 1.2%;
orthopedic disabilities, 1.2%; visual impairments, 0.4%;
and autism, 0.1%. Among the children with disabilities,
more boys than girls were victims of neglect, physical
abuse, and emotional abuse. For sexual abuse, more dis-
abled girls than boys were victims. Children with disabil-
ities were maltreated at earlier ages than their nondisabled
peers with the majority maltreated between birth and
5 years of age. Preschool-age disabled children experi-
enced more neglect, physical abuse, emotional abuse, and
sexual abuse than children in elementary, middle, and high
school. Child abuse and neglect have a deleterious effect
on disabled children’s abilities to benefit from special
education services. Maltreated children with disabilities
have significantly lower math and reading achievement
than nonmaltreated disabled peers and both abused and
nonabused peers without disabilities. Maltreated children
with and without disabilities miss significantly more school
than nonmaltreated peers. The relative risk for maltreat-
ment among children with disabilities is 3.44 times that of
nondisabled children. School professionals need to be
cognizant of the high base rate of maltreatment among the
children they serve. Prevention efforts need to concentrate
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on young children with disabilities and their families, the
period of maximum risk. The gender findings reflect the
greater prevalence of disabilities among males. Other
research (Sobsey 1994) has identified large numbers of
male victims among disabled maltreated children. Given
the high expense associated with special education ser-
vices, the maltreatment of disabled children needs to be
addressed in order to optimize its beneficial effects for one-
third of the disabled school-age population. Attendance
data including tardiness is a marker to be monitored by
maltreatment sentinels for both disabled and nondisabled
children. Prevention efforts need to address risk factors
determined by both disability and maltreatment type.
Child Abuse and Neglect Incidence Studies in Law
Enforcement Settings
Both the hospital and school-based population research
completed by Sullivan and Knutson (1998a, 2000a) con-
tained unexpected cohorts of runaways. Therefore, the
prevalence of disabilities among runaways in both popu-
lations was examined (Sullivan and Knutson 2000b). A
total of 255 runaways were identified in the 39,353 hospital
records and 562 runaways in the total school population of
40,211 children and youth. The prevalence rate of dis-
abilities among the maltreated runaways was 83.1% com-
pared to 47% among the nonmaltreated runaways in the
hospital sample. In the school sample, 34% were mal-
treated runaways and 17% had no records of maltreatment.
Behavior disorders, mental retardation, and some type of
communication disorder were found to be the most pre-
valent disabilities in runaway children in both samples.
Maltreated children, with and without disabilities, exposed
to sexual and physical abuse in the home were at high risk
to run away. Also, a higher prevalence of families with
records of domestic violence had runaways with behavior
disorders than families without a record. An association
between lower academic achievement, poor school atten-
dance, family stress factors, and maltreatment and dis-
ability was found in runaway youth. These findings have
implications for researchers and service providers. Chil-
dren and youth with disabilities are unidentified and
unrecognized among runaways in law enforcement records
of maltreatment. Researchers studying runaways might
explore their samples for youth with disabilities and
include disability status in research protocols. Prevention
materials targeted toward runaway youth should address
the cognitive and language deficits many of these youth
possess.
Children and youth with disabilities have received
recent attention in the juvenile justice literature. Available
research does not provide sound prevalence data addressing
the overrepresentation of youth with disabilities, primarily
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Clin Child Fam Psychol Rev (2009) 12:196–216
learning disabilities, in the juvenile justice system (Mears
and Aron 2003). Three theories have been posited to
account for the observed presence of large cohorts of youth
with learning disabilities in juvenile justice programs. The
School Failure Hypothesis posits that the presence of a
learning disability leads to school failure which in turn
leads to a negative self-image, dropping out of school, and
engaging in delinquent behavior because of associating
with delinquent-prone peers (Briere 1989; Larson 1988;
Levin et al. 1985). The Differential Treatment Hypothesis
contends that youth with learning disabilities are more
likely to come to the attention of authorities and then
receive differential processing within the juvenile justice
system (Briere 1989; Larson 1988; Mears and Aron 2003).
The Susceptibility Theory posits that youth with disabili-
ties are more likely than nondisabled peers to engage in
delinquent behavior because of specific characteristics
putatively associated with various disabilities (Briere 1989;
Larson 1988; Mears and Aron 2003). There is limited
empirical support for any of these theories and the research
that has been undertaken has relied upon inconsistent
definitions of disabilities, employed data only from incar-
cerated populations, and presupposed a causal relationship
between learning disabilities and juvenile violence (Mears
and Aron 2003; Malmgren et al. 1999). There is a critical
need for theory-driven research with access to juvenile
justice, special education, and mental health records to
identify associations and pathways between disabilities and
juvenile justice outcomes.
Child Abuse and Neglect Incidence Studies in Social
Service Settings
Shortly after the completion of the Second National Inci-
dence Study (NIS-2 1988; Office of Human Development
Services 1988), the National Center on Child Abuse and
Neglect (NCCAN) contracted with a private corporation,
Westat, Inc., to conduct a study of the incidence of child
abuse among children with disabilities. The resulting We-
stat study mirrored the methodology implemented in NIS-
2. Accordingly, data were collected from 35 CPS agencies
that were statistically selected to be nationally representa-
tive of U.S. counties. This limited the study to maltreat-
ment cases identified in CPS agencies alone and neglected
to include information from law enforcement agencies that
typically are repositories of extrafamilial abuse records.
Results indicated that 14.1% of children in a nationally
representative sample with substantiated maltreatment by
Child Protective Service (CPS) workers had one or more
disabilities. A weakness of this study is the identification of
disabilities on the basis of social worker opinion rather than
implementing a validated disability definitional framework.
It was concluded that children with disabilities were 1.7
Clin Child Fam Psychol Rev (2009) 12:196–216
times more likely to be victims of child maltreatment in
comparison to children without disabilities. Results also
indicated that some disabilities, such as physical health
problems and serious emotional disturbance, were associ-
ated with increased maltreatment, while mentally retarded
children and those with speech/language disabilities did not
demonstrate a statistically significant increase in incidence
of maltreatment. The study also reported that specific
learning disabilities were associated with a very large
decrease in risk for maltreatment. An unusual finding was
that children with disabilities were most likely to be white
males 5 years of age or older from one-child families.
These findings are likely artifacts due to the implementa-
tion of a nondisabled control group of children that did not
match the disabled group exactly on age. The control group
used in the study was not appropriate because it was con-
structed from an Office of Education study of school
children between the ages of 6 and 17 years ; the abused
children in the Westat sample were ages 0–17 years with
almost 40% of the children under 6 years of age. Since age
was not controlled in the analyses, comparisons cannot be
made between the two groups. Although the Westat, Inc.
(1993) study found that there is an association between
disabilities and maltreatment, methodological limitations
precluded strong inferences from the study.
A large-scale longitudinal study followed the involve-
ment of 7,940 children reported for maltreatment through
the child welfare system and into special education in St.
Louis (Jonson-Reid et al. 2004). Children identified in
administrative databases that included Medicaid health
records, Child Protective Service records, child welfare
services information, and special education records were the
subjects followed. Thus, all the children were from low-
income families. The dependent variables were both dis-
ability related and encompassed eligibility for special edu-
cation and type of disability for which the child received
services. Child maltreatment predicted later special educa-
tion entry. Children with records of sexual abuse had lower
rates while child victims of physical abuse had higher rates
of subsequent special education entry. The rate of entry into
special education was high for children receiving family
preservation services or foster care subsequent to maltreat-
ment. This study provided evidence that maltreated children
have a significant risk of later special education placement.
The study design precluded the identification of the presence
of a disability prior to the occurrence of the maltreatment.
However, it presents compelling evidence that special
education is a potential outcome of child maltreatment
among low-income children. This methodology needs to be
replicated with children from other socioeconomic strata in
other locales in the U.S.
Shannon and Agorastou (2006) investigated the ability of
child protection service (CPS) agencies to identify children
203
with developmental disabilities exposed to maltreatment as
well as the level of developmental disability-related training
that CPS staff receives. Earlier work revealed that CPS
workers rarely recorded disability status in their case files
(Bonner et al. 1997). Questionnaires were sent to child
welfare administrators in all 50 states and the District of
Columbia. There was a very high response rate with 50 out
of a possible 51 respondents returning the questionnaire.
Alarmingly, less than 50% of state child welfare agencies
identified children with developmental disabilities. The
administrators were asked to rate the accuracy of the dis-
ability data submitted by local CPS agencies to the state’s
central office and the median response was ‘‘somewhat
accurate.’’ The majority of states (68%) provided disability
training to workers with in-service workshops. Others pro-
vided consultants, hand-outs, and written materials for
training workers. Unfortunately, the agency administrators
reported that they did not typically seek consultation from
developmental disability agencies in their states. The
authors concluded that state CPS agencies were better pre-
pared 20 years ago to identify and document children with
disabilities in their caseloads than they are currently. Rec-
ommendations were made for improved data collection
procedures, staff and foster family training on disability
issues, and improved collaboration with disability-related
providers. This does not bode well for the success of the
Fourth National Incidence Study (NIS-4) in determining the
incidence of maltreatment among children with disabilities.
The NIS-4 methodology is obtaining disability data from
CPS agencies in 35 counties throughout the U.S. (Andrea
Sedlacek, personal communication, August 13, 2008). The
Shannon and Agorastou data indicate that the disability
determinations by CPS agencies throughout the U.S. are
fraught with validity and reliability problems that would
preclude their use in research.
Connell et al. (2007) examined the link between child,
family, and case characteristics with the risk of re-referral
to child protective services (CPS) for child maltreatment
using the administrative data that included submissions to
the National Child Abuse and Neglect Data System
(NCANDS) in the state of Rhode Island between 2001 and
2004. The dataset included 22,584 children from infancy to
late adolescence. The study found that the time of greatest
risk for re-referral is the initial 6-month period following
the initial case disposition. Family poverty was the best
predictor of re-referral. Children with an identified dis-
ability were 1.33 times more likely to be re-referred to
Child Protective Services than children without a disability.
Identified family risk factors were substance abuse history,
poverty, and domestic violence history. Families facing
multiple contextual stressors had the highest risk for re-
referral suggesting that a prevention window exists
immediately after case closings.
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Two population-based studies conducted in Great Brit-
ain and one in Israel addressed the incidence of disabilities
in child abuse registries. In a retrospective whole-popula-
tion cohort study, data were drawn from the West Sussex
Social Services’ Child Protection Register in the United
Kingdom (Spencer et al. 2005). Participants were 119,729
children born in West Sussex between January 1983 and
December 2001. The study assessed the risk of registration
for child abuse, including neglect, physical abuse, sexual
abuse and emotional abuse, among a variety of disabling
conditions. These were cerebral palsy, autism, conduct
disorder, nonconduct psychological disorders, speech and
language disorders, learning disabilities, and vision and
hearing disabilities. A significant association between
specific disabling conditions and a record of child mal-
treatment was identified. Furthermore, this association
varied with type of disability and the abuse category.
Cerebral palsy, conduct disorders, and learning disabilities
were associated to all categories of abuse (physical, sexual,
emotional, and neglect) while autism and sensory disorders
were not related to any type of abuse. This variability in
association data is consistent with the Sullivan and Knut-
son (2000a) findings in a school- based population wherein
relative risks for type of maltreatment varied with disability
status.
Data on 14,256 children born between April 1991 and
December 1992 from the Avon Longitudinal Study of
Parents and Children (ALSPAC) were examined for asso-
ciated factors with child maltreatment (Sidebotham et al.
2003). Participants were 14,256 children born between
April 1991 and December 1992 who are followed longi-
tudinally. Data were drawn from the social services’ child-
protection registers (United Kingdom) and reviewed for
possible child abuse records of neglect, physical, sexual,
and emotional maltreatment. A total of 115 maltreated
children were identified. Disabilities were identified by
parental reports. Parents reported developmental concerns
regarding speech, behavior, and general development.
Differences in birth weight, overall health, developmental
milestones, and behavior were identified in the maltreated
children compared to nonabused children. Sidebotham
et al. (2003) concluded that the overall circumstances and
conditions that occasion child maltreatment are a complex
compendium of factors in which child characteristics play
only a small part. The significance of this research is the
determination that the disability status of the child is only
one component of the disability/abuse equation and that
other contextual factors also play a role.
A study conducted in Israel examined the reports of
forensic investigations from 1998 to 2004 of alleged vic-
tims of sexual and physical abuse that included 40,430
children between the ages of 3 and 14 years (Hershkowitz
et al. 2007). There were 4,461 children with identified
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Clin Child Fam Psychol Rev (2009) 12:196–216
disabilities in this cohort. It included children with the
following identified disabilities: emotional and behavioral
disorders, pervasive developmental disorders, mental
retardation, brain injury, communication and learning dis-
orders, physical impairment and health-related problems,
sensory impairment, and multiple disabilities. All children
were interviewed using the National Institute of Child
Health and Human Development (NICHD) interview pro-
tocol. A researcher-developed classification system cate-
gorized the disabilities as minor or severe based on
researcher judgment of the children’s’ functioning during
the interview. Children with minor disabilities and severe
disabilities were identified in this manner. No rater reli-
ability data are given regarding this classification system.
Children with disabilities were more likely to be victims of
child abuse and exhibit more difficulty reporting their
abuse experiences when interviewed regarding them. The
most prevalent form of maltreatment among the children
with disabilities was sexual abuse. No age differences were
found in the relation between disability and abuse. Children
with disabilities failed to disclose abuse more often com-
pared to children with no disabilities. Delay in disclosure
was reported for children with disabilities specifically for
the victims of sexual abuse compared to children with no
disabilities. This research provides ground breaking infor-
mation on interviewing protocols for use with children with
disabilities. However, the researchers’ disability classifi-
cation method needs to be validated. Further research is
needed to determine whether the results generalize to
children with disabilities in other countries. The subjects
were all Israeli children and no data on the ethnic com-
position of the cohort was provided. It is unknown if any
Palestinian or other Arab nationalities were represented in
the social service database from which the cohort was
obtained. Given the violence-ridden context of the region,
opportunities for the study of community violence, war,
terrorism, and religious violence among children with
disabilities are abundant.
The studies discussed in this review have demonstrated
evidence of an association between disabilities and mal-
treatment in children. Children with disabilities have been
found at increased risk for child maltreatment in studies
conducted in medical, child protective services, law
enforcement, and school settings in the U.S., Canada, Great
Britain, Norway, Australia, and Israel. But critical gaps
remain in the elucidation of the disability–maltreatment
equation. There is much more that we need to know.
Kendall-Tackett (2005) made a plea to researchers in the
child maltreatment field to include the disability status of
children in their research protocols. Even without a focus
on children with disabilities, such research would provide
additional and needed data on the scope of the problem and
expand the breadth and depth of current work. At some
Clin Child Fam Psychol Rev (2009) 12:196–216
point, disability status should be considered as a categorical
variable akin to gender, age, and ethnicity and routinely
included in research protocols.
Domestic Violence
Contextual factors occur in tandem with violence exposure
among children with and without disabilities and serve as
moderators or mediators of its effects. Nondisabled chil-
dren’s exposure to violence rarely occurs in discrete, uni-
tary forms (Dodge et al. 1997; Margolin 1998; Rossman
and Rosenberg 1998) and often co-occurs with other types
of violence, particularly domestic and community violence
(Herrenkohl and Herrenkohl 2007; Lee et al. 2004; Hartley
2002; McGuigan and Pratt 2001). High rates of co-occur-
rence between exposure to domestic violence in the home
and child physical abuse have been reported (Renner and
Slack 2006). Studies have also identified other co-occur-
ring risk factors associated with child abuse and domestic
violence exposure including: fathers’ use of drugs, alcohol,
and arrest for criminal offenses (Hartley 2002); mental
illness, substance abuse, and criminal activity within a
family member (Dong et al. 2004); lower education, poor
health, and drug use by the father (Tajima 2004); and
poverty (Gewirtz and Edleson 2007; Lee et al. 2004).
Currently, there is limited research on the co-occurrence
of different forms of violence among children with dis-
abilities. Domestic violence was found to co-occur with
child maltreatment in the homes of children with disabili-
ties in Sullivan and Knutson’s (2000a) school-based study.
There were records of domestic violence within the fami-
lies of 17.2% of the children and youth with disabilities and
16.3% of nondisabled children and youth in that research
which involved 4,503 maltreated children (Sullivan 2006).
The difference in rate between disabled and nondisabled
children was not significant. Behavior disorders, mental
disabilities, and speech/language disorders were the pri-
mary types of disabilities among the disabled maltreated
children with a record of domestic violence in their fami-
lies. No data regarding the incidence of domestic violence
absent child maltreatment were available. The 17% rate of
domestic violence in the home among children with dis-
abilities in this population is almost three times higher than
the base rate of 6% co-occurrence between domestic vio-
lence and child physical abuse in other community samples
(Appel and Holden 1998).
Maltreated children with disabilities are also exposed to
a host of additional stressful life events (Sullivan and
Knutson 2000a). In that research, the following family
stress factors were found significantly more often in the
maltreatment records of disabled children with a domestic
violence history in their family than in the families of
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maltreated disabled children without a domestic violence
history (Sullivan 2006). These include: voluntary foster
care placement in nonkinship care families; inadequate
parenting and inadequate housing; family financial prob-
lems; marital problems; pregnancy or birth of newborn;
parent ill/disabled; mental/emotional problems in parent;
parental alcohol/drug abuse; social isolation; family
involved with the legal system; step-parent/child conflict;
fetal alcohol syndrome; and AIDS in family member
(Sullivan 2006). These findings suggest the existence of
disability-specific family factors in the domestic violence–
child maltreatment equation in need of identification to
guide prevention and intervention efforts.
Although not all children from violent homes develop
mental health and behavior problems (Margolin and Gordis
2000), there is evidence that exposure to domestic violence
can occasion disabilities, namely Conduct Disorder (CD)
and Attention Deficit Hyperactivity Disorder (ADHD).
Litrownik et al. (2003) examined the relationship between
family violence and behavior problems in a sample of 682
children and youth. Family violence was defined as both
violence directed at and violence witnessed by the child
and coded for the presence of physical and/or psycholog-
ical acts of aggression. Behavior problems were identified
among children experiencing family violence as a function
of type of aggression associated with the violent act. Psy-
chological and physical violence in combination were
related to aggressive behavior in the child, while witness-
ing psychological violence was related to anxiety and
depression (Litrownik et al. 2003). Similarly, when
examining the impact of family violence on the develop-
ment of attention and conduct problems in children, Becker
and McCloskey (2002) found that boys had more attention
problems, conduct problems, and reports of violent offen-
ses than girls, and children who developed Conduct Dis-
orders were more likely to have co-morbid ADHD (Becker
and McCloskey 2002).
There is a gap in the knowledge base on which children
develop aggression, depression, or anxiety and their char-
acteristics (Jouriles et al. 2001). Studies are also needed on
the different effects of violence exposure on the mental
health of boys and girls at different ages. In a sample of
120 children of adult perpetrators and victims of domestic
violence, the children witnessing the violence exhibited
differential emotional and behavior problems depending on
age and gender (Anderson and Sullivan 2005). Young girls
between 1‘ and 5 years of age who witnessed domestic
violence had significantly more depression and sleep
problems than both exposed boys of the same age and a
control group of children not exposed to domestic violence
in the home. School-age and adolescent girls (i.e., between
the ages of 6 and 18 years) exposed to domestic violence in
the home exhibited significantly more aggressive behavior
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than boys exposed to domestic violence and nonexposed
controls. In this sample, girls appeared to have more
adverse behavior consequences to witnessing domestic
violence in the home than boys. These include depression
and sleep disturbances in early childhood and aggressive
behavior in the elementary school years and adolescence.
An area of research related to behavior and mental
health problems among the siblings of children with dis-
abilities has emerged. Behavioral outcomes have been
identified in siblings of children with speech and language
disabilities that can mediate sibling aggression and include
jealousy, resentment, and loss of parental attention (Barr
et al. 2008). Siblings of maltreated children are also at an
increased risk of abuse in households in which parents have
mental health problems, frequent use of alcohol and drugs,
intellectual disabilities, and a history of abuse in childhood
(Hamilton-Giachritsis and Browne 2005). Subjects for this
research were 795 siblings from a cohort of 400 children
who had been referred to police child protection units in
England for some form of abuse and/or neglect. The risk of
siblings’ maltreatment was associated with child charac-
teristics including age, behavior difficulties, physical or
intellectual disabilities, and gender. Family characteristics
such as size, criminality, financial problems, a violent
family environment, and social isolation were also asso-
ciated with sibling abuse. It is noteworthy that this research
also concluded that the special victim model of a step or
child with a disability had limited rather than universal
application in their sample. The generalizability of these
findings to American families referred to child protective
services needs to be determined. Support groups for the
siblings of disabled children that address the development
of coping strategies, social interaction with the disabled
sibling, building self-esteem, and the understanding of
disability-related issues have been shown to be effective in
addressing sibling problems that arise in these families
(Naylor and Prescott 2004).
Sobsey (2001, 2007), a Canadian scholar on violence
against persons with disabilities, has done seminal work in
collecting data and studying the filicide of children with
disabilities. The murder of a child by a parent is an extreme
manifestation of domestic or family violence. Sobsey’s
major focus has been on the interpretation of such child
murders as altruistic on the parent’s part. In Canada, some
50 children are murdered each year and 80% are murdered
by one or both parents (Sobsey 2001). In turn, about half of
these parents claim altruistic reasons for their actions that
include the unbearable burden of the child’s disability to
the parents, an act of love on the part of the parents to spare
the child the burden of the disability, and even for the good
of the child. The Tracy Latimer case in Canada engendered
some sympathy for the father who murdered her and
resulted in a copy-cat murder of a disabled child in another
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Canadian province (Sobsey 2001). There appears to be a
much higher rate of filicide in Canada than in the U.S. The
percentage of child murders attributed to filicide in Canada
is 80% compared to 55% in the U.S. Sobsey opines that
this is due to the positive and sympathetic publicity
afforded to Tracy Latimer’s father during his trial. In the
U.S., only 3% of child homicides involve children (Rich-
ards 2000). Although the murder of a disabled child by a
parent is a low base rate occurrence, professionals need to
be cognizant of its potential role and outcome in the vio-
lence victimization of children with disabilities.
Community Violence
Minimal research has been conducted on infants, toddlers,
children, and youth with disabilities as victims of con-
ventional violent crimes, including homicide, assault,
sexual assault, theft, and robbery within their communities
(Sullivan 2003a, 2006). This is because crime victimization
data are typically not collected on children with disabili-
ties. Although in 1997 the FBI began collecting disability
status on victims of hate crimes in compliance with The
Violent Crime and Law Enforcement Act of 1994, data are
collected only on adults. However, even if data were col-
lected on children they would be problematic since the
determination of a disability in a victim and hate for that
particular disability as a motivation for their victimization
is determined by the police report completed by the
investigating officer. Although it is likely that there are
cohorts of children with disabilities among the existing
datasets on nondisabled children, they remain unrecog-
nized and unidentified within criminal justice databases on
crimes against children in the U.S. (Sullivan 2003a, 2006).
A comprehensive literature search was completed by
searching each of the conventional violent crimes (i.e.,
homicide, assault, sexual assault, theft, and robbery) by
each childhood disability (i.e., behavior/emotional dis-
ability, visual impairment, deaf or hard of hearing, learning
disabilities, mental retardation, communication disorders,
speech and/or language disorders, health/orthopedic dis-
abilities, physical disabilities, autism, and multiple dis-
abilities) as victims of each conventional crime. None were
identified. This does not mean children with disabilities are
not victims of violence in the community and on the
streets. Rather, they are not coded as disabled in victim
crime reports collected by state and federal law enforce-
ment agencies in the U.S. This method can serve as a
barometer to monitor the tracking of research on commu-
nity violence that includes children with disabilities.
There are four types of community violence that impact
children and youth with disabilities and ironically occur
within institutions designed to serve them. These include
Clin Child Fam Psychol Rev (2009) 12:196–216
school bullying by peers, corporal punishment adminis-
tered within the school setting, physical and chemical
restraint used to modify behavior in some special schools
and mental health treatment centers, and systemic violence
in residential schools and institutions for children with
specific types of disabilities (Sullivan 2006).
School Bullying
School bullying involving children with disabilities has
been extensively studied in the United Kingdom and
Scandinavian countries (Dawkins 1996; Olweus 1991;
Roland and Munthe 1989). Bullying is defined as a rela-
tionship of unbalanced power between youth who are
involved in repeated abusive or threatening behaviors
toward other youth (Besag 1989; Olweus et al. 1999; Smith
and Brain 2000). Children with disabilities are the frequent
targets of physical and/or psychological teasing, name-
calling, hitting, pushing, social exclusion, threats, extor-
tion, and theft in schools (Dawkins and Hill 1995). Chil-
dren enrolled in special education programs associated
with visible disabilities (i.e., cerebral palsy, blindness,
deafness, etc.) are twice as likely to be bullied than chil-
dren with disabilities not associated with visible physical
conditions (i.e., learning disabilities and behavior disor-
ders) and some one-third of these children are regularly
bullied at school with boys being bullied more often than
girls (Dawkins 1996). These data are consistent with other
research that has found children with special education
needs twice as likely to be bullied as those in regular class
placements (Olweus 1991, 1993; Whitney et al. 1992).
A study conducted in the United States, using data from
the National Survey of Children’s Health (NSCH), found
children with special health care needs 1.5 to 2 times more
likely to be victims of bullying than their nondisabled peers
(Van Cleave and Davis 2006). This study also determined
that children with special health care needs (CSHCN) were
most often victims rather than perpetrators of bullying.
CSHCN with an emotional, behavioral, or developmental
disability were more likely to be a bully or a bully/victim.
An Australian study by Piek et al. (2005) examined the
relationship between bullying and children with a visible
disability (i.e., Development Coordination Disorder).
Children with or without motor coordination problems
reported the same amounts of victimization. However,
verbal victimization profoundly impacted the self-worth of
girls with motor coordination problems (Piek et al. 2005).
A British study of children with intellectual disabilities
in two special education schools found 83% of the partic-
ipants experienced some type of bullying including verbal
vulgar epithets, ridicule, threats, physical beatings, being
forced to do things against their will, and being sexually
touched without their consent (Reiter and Lapidot-Lefler
207
2007). Furthermore, among children with intellectual dis-
abilities, such victimization was related to the children’s
emotional and interpersonal problems as well as anxiety,
depression, and peer rejection (Reiter and Lapidot-Lefler
2007). Interestingly, bullies and children who were both
victims and bullies exhibited challenging behavior in the
classroom including temper tantrums, unruly behavior,
lying, and stealing. Being a bully was related to both
aggressive behavior and hyperactivity (Reiter and Lapidot-
Lefler 2007).
Identified risk factors for bullying victimization include
shyness and seeking help (Mishna 2003), as well as low
self-esteem, poor social skills, and physical and mental
impairments (Flynta and Morton 2004). Children with
learning disabilities (LD) are at an increased risk of vic-
timization but there is little research available on the
relationship between children with LD and bullying (Mis-
hna 2003). It is hypothesized that children with LD tend to
have low social status and poor peer relationships (Boivin
et al. 1995) and rejection by peers renders the LD child
susceptible to bullying victimization (Boulton 1995, Egan
and Perry 1998, Hodges and Perry 1999). Children with
Attention Deficit Hyperactivity Disorder (ADHD), a com-
mon neurobehavioral childhood disorder that often is co-
morbid with LD, have a higher risk for both bullying others
and being a victim of bullies (Unnever and Cornell 2003).
Interestingly, children taking medication for their ADHD
were more likely to be bullies and this was attributed to the
medication-induced lowered self-control (Unnever and
Cornell 2003).
Bullying among deaf children has been studied in school
settings (Weiner and Miller 2006). Deaf and hard-of-
hearing children can be targets by their deaf and hearing
peers. It is important to study bullying in differing deaf
school settings attended by deaf and hard-of-hearing stu-
dents. Researchers also need to examine the following
factors unique to deaf children: children who are deaf and
developmentally disabled, deaf children of hearing parents,
deaf children of deaf parents, deaf children in residential or
day programs, and deaf children in mainstreamed or self-
contained classrooms (Weiner and Miller 2006). A pilot
study of deaf youth in a residential school examined 13
boys and 6 girls between 13 and 17 years of age for bul-
lying, victimization, and any emotional or behavioral
manifestations the students attributed to the bullying
(Sullivan 2006). There was no indication of more bullying
behavior toward other students compared to the hearing
normative sample of the Reynolds Bully Victimization
Scales for Schools (Reynolds 2003). However, there were
more victims of bullying with higher severity levels com-
pared to the hearing norms. There was no association
between gender and age of the deaf youth and bullying
perpetration or victimization. Symptoms were reported by
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the majority of deaf students in their self reports in addition
to being a victim of bullying at school. There was an
association between being a victim of school bullying and
having feelings of anger, irritability, and aggressive
behaviors among deaf youth. These pilot data apply only to
children in residential schools and need to be replicated in
other school settings serving deaf children. School bullying
is a contributing factor to feelings of unhappiness, sadness,
and anger among children with disabilities, and it affects
their ability to benefit from special education services
(Sullivan 2003a, 2006).
Physical Restraint and Seclusion (R & S)
Condoned physical interventions and seclusion dispensed
under the guise of therapeutic interventions implemented
with children with disabilities can escalate to abusive
violence and are both controversial and commonplace
(Sullivan 2003a, 2006). Restraint is the restriction of
movement by using force. There are three types of
restraint. Physical restraint entails restricting movement by
a person holding, sitting, or lying on the child. Mechanical
restraint involves the use of a device to limit a child’s
movement such as a harness, gurney, or strapping a youth
in bed. Chemical restraint entails the use of medication to
lessen agitation which can result in a youth becoming
unconscious. All three forms of restraint are used with
children with disabilities in residential treatment centers,
psychiatric hospitals, residential schools, and institutions.
Seclusion is the involuntary confinement to a room, chair,
or other area from which the youth is prevented from
leaving. This can be a ‘‘quiet room,’’ the youth’s bedroom,
or a specially reserved room within the facility. Mental and
behavior disorders are considered a disability under IDEA
and a special health care need in the National Survey of
Children with Special Health Care Needs (NS-CSHCN).
Accordingly, essentially all children and youth receiving
inpatient treatment for a mental or behavior disorder could
be considered as manifesting a disability.
National attention has been afforded to the practice of
physical restraint against children and adolescents in psy-
chiatric and residential treatment centers (Mohr et al.
2003). The consequences of restraint can be extensive and
wide ranging. They include restraint asphyxia; blunt
trauma to the arms, chest, and legs; catecholamine rush;
rhabdomyolosis; thrombosis; broken limbs; and even death
(Mohr et al. 2003). The psychological and cognitive impact
of physical restraint includes nightmares, disturbing
thoughts, fearfulness, avoidance behaviors, mistrust of
mental health workers, and anxiety (Mohr et al. 2003).
There is increasing concern over incidents of death and
injury resulting from restraint (Mohr et al. 2003). Although
deaths due to restraint must be reported under Centers for
123
Clin Child Fam Psychol Rev (2009) 12:196–216
Medicare and Medicaid Services (CMS) standards for all
health care providers that receive federal monies, the
Health and Human Services Office of Inspector General
Report on individual state abuse and neglect laws indicated
that state systems and laws for protecting children and
youth with disabilities from abuse and neglect vary. Fur-
thermore, the report found that up to 90% of persons with
disabilities reside in facilities such as group homes, resi-
dential schools, and supervised apartments that do not
receive Medicaid or Medicare funding and, therefore, are
not covered by CMS standards (Gross 2003). Thus, not all
deaths of children and youth with disabilities residing in
group homes and residential schools due to restraint are
likely reported. Neither the number of children with dis-
abilities who died from restraint nor the number who
developed a disability resulting from restraint are compiled
or known.
Restraint and seclusion remain controversial treatment
modalities for children and youth in out-of-home place-
ments. Both media and national legislative attention have
spawned the need for valid and reliable national data on the
use of these practices and their efficacy in treating mental
and behavior disorders among children and youth. There
appears to be a circularity of association between aggressive
behavior and restraint. That is, children exhibit aggressive
behavior and are restrained for doing so and, in turn, display
aggressive behavior after the restraint has ended. This
association was found among mentally retarded children in
psychiatric inpatient facilities (Sukholdolsky et al. 2005).
Similarly, in an extensive study of aggression among psy-
chiatrically hospitalized youth, Boxer (2007) reported that
youth becoming involved in seclusion and restraint because
of aggressive behavior have histories of various types of
aggression prior to hospitalization.
Restraint and seclusion have been mandated as ‘‘last
resorts’’ in the treatment of children and youth with severe
behavior and mental disorders. The Substance Abuse and
Mental Health Services Administration (SAMHSA) has
placed the elimination of restraint and seclusion on its
research priority and funding agenda. Efficacy data are
urgently needed to compare physical restraint with other
behavioral interventions in children and youth with dis-
abilities in residential mental health settings.
Corporal Punishment
Corporal punishment is allowed in 21 states in the U.S. and
is frequently used in 13 of these states. Corporal punish-
ment includes the physical striking of children and youth
with hands and/or objects, physical exercise as punishment,
and the completion of humiliating cleaning or other phys-
ically repetitive tasks dispensed by teachers, aides, and
administrators within the schools. Minorities and students
Clin Child Fam Psychol Rev (2009) 12:196–216
with mental or physical disabilities are more likely to be
paddled than Caucasian students (Human Rights Watch
and American Civil Liberties Union Joint Report 2008).
Data released by the National Coalition to Abolish Cor-
poral Punishment in Schools (NCACPS) in March 2008
reported that 223,190 students in the United States received
some form of corporal punishment in U.S. public schools
during the 2006–2007 school year This NCACPS report
identified four groups of children as the most frequent
recipients of corporal punishment: poor children, minori-
ties, children with disabilities, and boys (National Coalition
to Abolish Corporal Punishment in Schools 2008).
Given that 21 states permit corporal punishment within
their public schools, the physical striking of children as a
means of school discipline remains a controversial issue in
the U.S. Indeed, the existence of corporal punishment of
children in some U.S. schools is one of the reasons the U.S.
has not ratified the United Nations Declaration on the
Rights of the Child, which specifically lists a child’s right
not to receive corporal punishment. There are emerging
data that this sanctioned corporal punishment in schools is
linked to school shooting fatalities (Arcus 2002) and stu-
dent aggressive misbehavior (Hyman and Perone 1998).
The use of aversive interventions and restraints with
children with disabilities is often considered necessary and
even beneficial to their overall treatment and well-being.
These can include the use of shock wands as prods to
follow directions, spraying ammonia mist in the face, and
forced ingestion of noxious substances as punishments.
Full-body restraint and seclusion have been also routinely
endorsed as ‘‘treatments’’ for children with disabilities. The
efficacies of these interventions have not been sufficiently
validated to justify or warrant their use.
Institutional Violence
Despite the introduction of the IDEA and the subsequent
inclusion of disabled children in regular education pro-
grams, significant numbers of disabled children continue to
be placed away from home and community. The most
recent data available indicate that approximately 2% of the
10.2 million children and youth with disabilities in the U.S.
reside in institutions, including nursing homes, schools for
the blind, deaf, and physically disabled, institutions for the
mentally retarded, and facilities for the mentally ill (Wal-
drop and Stern 2003).
The problem of violent acts committed against children
in institutions is long-standing and has been documented in
the historical records of the residential care of children for
over two centuries (Paul and Cawson 2002; Safford and
Safford 1996; Sobsey 2002; Sullivan 2003a, 2006). Dis-
abled children placed in institutions are less likely to
receive help from child protection and therapeutic services
209
due to institutional barriers that include self-investigations
of complaints of abuse and the tendency for social service
personnel to default to the institution professionals with
expertise in a given disability (Paul and Cawson 2002).
This can result in the maltreatment being explained and
misconstrued as a manifestation of the disability. Com-
munication difficulties are significant barriers that impede
investigations of maltreatment in residential facilities. This
is particularly problematic among children with develop-
mental disabilities, mental retardation, and sensory
impairments with compromised communication skills and
limited linguistic communities that compound and con-
found interviews with the suspected victim. Although the
use of interpreters is helpful with deaf children in resi-
dential schools, it does not always solve the problem.
These communication difficulties often result in charges
not being filed against likely perpetrators because the child
is not believed or deemed a good witness because of the
disability. Barring an eye witness or a confession, the
alleged maltreatment is not investigated.
Children with sensory impairments are at increased risk
for maltreatment (Brookhouser 1987;Sobsey 2002; Whi-
taker 1987). Numerous states in the U.S. and provinces in
Canada have had major child abuse investigations in resi-
dential schools and institutions for children who are deaf
and hard of hearing, with visual impairments, and with
developmental disabilities (Brookhouser 1987; Sobsey
1994; Sullivan and Knutson 1998b; Sullivan et al. 2000). A
residential placement is a major risk factor for experiencing
sexual and/or physical abuse. Studies have demonstrated
that the primary location is the dormitory, and the primary
perpetrators are houseparents, older students, and peers
(Sullivan and Knutson 1998b). Sexual abuse tended to
occur in bathrooms, bedrooms, and specialized transpor-
tation, places within dormitory settings that are not always
closely monitored by staff (Sullivan et al. 1987, 2000;
Sullivan and Knutson 1998b). A residential school place-
ment coupled with physical and sexual abuse victimization
within the school increases the risk for alcohol abuse,
behavior management problems, and the perpetration of
sexual and physical abuse against peers among deaf males
(Sullivan and Knutson 1998b).
This research and highly publicized episodes of abuse at
residential facilities for children with disabilities that erupt
from time to time in the media suggest that current insti-
tutional practices, including condoned physical interven-
tions, which can escalate to abusive violence of residents
by their caretakers, should be closely monitored and
evaluated for their treatment efficacy. Disabled children
and youth placed in institutions intended to protect, nur-
ture, and educate them experience a breach of trust by
abusers employed in the facility (Sobsey 2002). The
numbers of children and youth with disabilities housed in
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210
institutions warrant more research on the prevalence, nat-
ure, and risk factors for violence and abuse in residential
settings.
In conclusion, a consideration of community violence
demonstrates a need for data on the prevalence, nature, and
effect of violent acts committed against children and youth
with disabilities by peers, schoolmates, and professionals
charged with their care and welfare. Currently, with the
exception of corporal punishment, it is unknown if children
and youth with disabilities have a higher victimization rate
of these types of violence than nondisabled peers.
War and Terrorism
In 2005, the Secretary General of the United Nations
undertook a study of violence against children around the
world and included children with disabilities. The study
estimated that 200 million children (10% of the world’s
children and youth) are born with a disability or become
disabled before the age of 19 (United Nations Secretary
General’s Study on Violence against Children 2006). The
study found that children with disabilities are exposed to
physical, sexual, and emotional violence, verbal abuse, and
neglect in a variety of settings including the home, at
school, in institutions used to provide them shelter, within
the juvenile justice system, community, and places of
employment throughout the world. Additional areas of
concern identified were children becoming disabled due to
contact with landmines, intentional maiming by soldiers,
conscription as child soldiers, and as a result of criminal
and gang activity within cities.
The paucity of data on violence perpetrated against
children with disabilities in the U.S. pales in comparison to
even scarcer international data (Sullivan 2006). Record
keeping is routinely poor in many parts of the world and is
further disrupted during warfare and terroristic attacks
(Zwi et al. 1999). Between April 2004 and October 2007,
children were actively involved in armed conflict in 19
countries or territories (Child Soldiers Global Report
2008). These children served as conscripted soldiers who in
addition to combatants were porters, cooks, and messen-
gers for adults in warfare activities (Child Soldiers Global
Report 2008). Perhaps the most heinous violence perpe-
trated against children with disabilities in warfare is their
use as suicide bombers primarily in Afghanistan by the
Taliban. An estimated 80% of Afghan suicide bombers had
physical or mental disabilities (United Nations Assistance
Mission to Afghanistan (UNAMA) 2007). In contrast to
other Arab nations, Afghan suicide bombers with disabil-
ities are not celebrated as martyrs. Persons with disabilities
are outcasts in Afghanistan and bring stigma and shame to
their families (UNAMA 2007). Many parents are unaware
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Clin Child Fam Psychol Rev (2009) 12:196–216
that their children have committed suicide in this manner.
Others have received money for their child’s suicide and
the family is honored for its collusion in the child’s
recruitment UNAMA 2007.
It is estimated that over 2 million children have been
killed in warfare and another 6 million have been rendered
permanently disabled as a result of combat injuries (Sev-
enth Report to the Security Council on Children and Armed
Conflict 2007). During armed conflict, girl soldiers are
subjected to rape and other sexual violence including
sexual slavery, forced prostitution, and sexual mutilation
(Child Soldiers Global Report 2008). This gender-based
sexual violence often results in physical and health-related
disabilities. The accidental detonation of unexploded
ordinance is a leading cause of disability in war-ravaged
nations (Francois et al. 1998) and children are frequent
victims (Andersson et al. 1995). An estimated half of the
15,000 to 20,000 annual victims of landmines and unex-
ploded ordnances in 90 countries are children (Office of the
Special Representative of the Secretary-General for Chil-
dren and Armed Conflict 2008). Nearly 10% of the popu-
lation in Cambodia is disabled, primarily due to land
mines, and children account for 20% of the disabled pop-
ulation (World Report on Violence and Health 2002). In
Iraq and Afghanistan, children are disabled by unexploded
ordinance at an alarming rate. Although the exact number
of children living without limbs in Iraq, as a result of
unexploded ordinance and countrywide warfare, is
unknown, local NGOs estimate that they must be in the
thousands (UN Office for the Coordination of Humanitar-
ian Affairs 2008).
Societal attitudes of shame toward families with dis-
abled children are commonplace in some countries and
cultures, particularly in Asia and Africa (Miles 1995).
Violence against children with disabilities is often due to
cultural prejudices and other emotional, physical, eco-
nomic, and social circumstances within the family. Women
are blamed for having a disabled child, and as a result, the
child is hidden, denied critical care, shunned, and neglected
by their families (Miles 1995). The cultural mores of
neglect and indifference toward children with disabilities in
the developing world is a contributing factor to their vio-
lence victimization. Devalued persons with disabilities are
at heightened risk to be victims of violence (Sobsey 1994).
Children with disabilities are used as income sources for
families in some cultures including their sale for sexual
favors and maiming them to enhance their appeal as beg-
gars (United Nations Secretary General’s Study on Vio-
lence against Children 2006).
The maltreatment of children with disabilities in insti-
tutional settings is ubiquitous throughout the world. It is
estimated that eight million boys and girls around the world
live in institutional care. Children residing in group homes
Clin Child Fam Psychol Rev (2009) 12:196–216
have a rate of sexual abuse four times higher than children
in family-based care. Children placed in residential insti-
tutions are six times more likely to experience violence
than children in foster care (United Nations Secretary
General’s Study on Violence against Children 2006). The
Secretary General’s study also identified institutional abuse
of children with disabilities within orphanages and resi-
dential settings. This abuse included neglect, denial of
critical care, and physical and sexual abuse. The study also
reported the long-term impact of institutionalization on
children that included severe developmental delays, the
acquisition of disabilities including cognitive, language,
visual, and hearing disorders, and increased rates of suicide
and recidivism in detention centers. Girls in detention
facilities are often subjected to sexual abuse and exploi-
tation. Sexual harassment and abuse in residential settings
is widespread in all countries of West and Central Africa.
Often the girls are raped in schools, dormitories, and hos-
tels. Studies completed in seven countries in the Middle
East and North Africa found that children with learning
disabilities were at an increased risk of being victims of
violence (UNICEF MENARO 2005).
The inclusion of the disability status of child victims in
the United Nations Secretary General’s Study on Violence
against Children provided needed data and knowledge on
the scope of violence exposure and victimization against
children with disabilities throughout the world. Such an
omnibus study is needed in the United States to identify
prevention and intervention targets and guide public policy
on children with disabilities throughout our nation.
Conclusions and Research Recommendations
Sufficient research evidence is available to conclude that
children and youth with some type of disability are at
increased risk to be a victim of some type of violence
during their infancy, toddlerhood, school years, or adoles-
cence. Children with disabilities need to be included and
counted in crime victim, child abuse and neglect, juvenile
justice, health care, and mental health national databases
(Sullivan 2003b, 2006). However, including and counting
them is a daunting task given that, with the exception of
health care and mental health agencies, many of these
entities neither acknowledge nor note the existence of a
disability among the children and youth in their care, much
less report their prevalence in databases to government
agencies and/or researchers. Given the heterogeneity in
definitional paradigms for a disability that are the gate-
keepers to services within education, health care, and
mental health settings, it is unlikely and perhaps unrealistic
that a standard ‘‘one agency fits all’’ definitional paradigm
for individual disability types across these settings will
211
ever be developed. For example, children with special
health care needs are identified on the basis of their specific
medical diagnoses, resulting treatment needs, and need for
financial assistance in obtaining medical services and this
is not the case for all children and youth with disabilities.
Children and youth in educational settings qualify for
special education services because of specific educational
services defined by federal law and determined by indi-
vidual evaluation by a team of certified educational spe-
cialists. Differential physical and mental characteristics are
required for categorization in a given disability grouping
and they differ across settings.
Although the multiplicity of definitional frameworks
impedes research, they do not prevent it. Indeed, their
diversity adds to the richness of the potential omnibus
study of the epidemiology of violence among children and
youth with disabilities that needs to be undertaken. Such a
study would encompass separate disability components and
investigate individually the incidence rates of violence and
children with disabilities within medical, crime victim,
child abuse and neglect, educational, juvenile justice, and
mental health settings. Valid and reliable research can be
undertaken with children with disabilities by choosing a
definitional paradigm and adhering to it throughout a
research protocol. Overlap in disability type can occur
across settings and needs to be investigated as the presence
of a disability can potentially affect a child or youth’s
violence victimization characteristics and/or progress
within a given setting. For example, children with learning
disabilities may have differential violence victimization
characteristics in crime victim and child maltreatment
databases and require specific accommodations to inter-
ventions within juvenile justice, educationa,l and mental
health settings.
Children and youth with disabilities were included as a
specific subpopulation in Healthy People 2010 for the first
time since the inception of the national health promotion
and disease prevention agenda in 1979 (Sullivan 2003a).
This objective was to reduce the number of children with
disabilities who feel happy, sad, or depressed. They will
also be included in the objectives of Healthy People 2020
as an added group to all objectives, rather than in a single
chapter limited to 6 objectives. This will include them in
the violence victimization prevention objectives and,
accordingly, adds them to the federal public health and
research agenda as a targeted population. Thus, the way is
open to add samples of children and youth with disabilities
to grant applications for federal funds as a bona fide
grouping included in our nation’s omnibus health agenda.
Doing so also enhances the public health relevance of
research projects. Hopefully, this inclusion will serve as a
catalyst for the public policy arena. A national public
policy blueprint that addresses violence against all people
123
212
with disabilities is needed to guide not only research but
public policy and practice (Marge 2003; Sullivan 2003a).
In a national call to action addressing violence against
children and adults with disabilities, Marge (2003) rec-
ommended a standardized and comprehensive approach in
the development of a national system of data collection on
violence. She recommended that all existing surveillance
systems that collect data on violence victimization include
questions about the disability status of victims. Further-
more, data collection efforts at the federal level should be
overseen and coordinated by an intergovernmental com-
mittee on violence and disability statistics. These recom-
mendations, to date, have not been implemented.
Researchers also need to do more than count and cate-
gorize the number of children with disabilities within a
particular definitional paradigm, be it medical, educational,
child protection, juvenile justice, or Social Security dat-
abases. The associations and pathways between disability
status and child maltreatment, domestic and community
violence exposure, and/or victimization are unknown and
need to be charted through research. The inability to link
data from disability sources to other datasets hampers
research efforts. Both public schools and the Social Secu-
rity Administration have disability databases on children
and youth that could assist in research in determining
disability prevalence rates of children and youth in health
care, social service, and law enforcement by permitting
data mergers between agencies with these databases to
identify the number of disabled children. Federal law does
not permit these mergers (i.e., Family Education Right to
Privacy Act-FERPA and the Social Security Act). Methods
congruent with federal statutes need to be identified to
permit this research. Waivers for researchers should be
both available and supported by database stewards. Data
should be collected and maintained on children with dis-
abilities between the ages of birth and 21 years.
Researchers addressing questions pertaining to children
with disabilities should have access to these databases.
Research methodologies for obtaining incidence data
need to be disability appropriate and not rely exclusively
on telephonic interviews, parents, and professionals to
identify the disability status of infants, toddlers, children,
and youth with disabilities. Persons with hearing impair-
ment and cognitive disabilities do not always respond well
to telephonic interviews. To study the association between
disabilities and violence exposure, it is important to adopt
procedures that will yield accurate professionally based
diagnoses of disability status as well as evidence of vio-
lence victimization. To this end, there is a critical need for
researcher access to depositories of data on children with
disabilities, their diagnostic histories, family and contex-
tual factors, and abuse and violence exposure histories.
Privacy laws are often interpreted to preclude this and
123
Clin Child Fam Psychol Rev (2009) 12:196–216
ironically protect privacy but prohibit the identification of
contextual factors that will lead ultimately to the preven-
tion of violence. We will never be able to identify path-
ways from disability to abuse and abuse to disability if
these access barriers are not removed. This access across
data repositories is the most efficacious and cost-effective
solution to the determination of the incidence of violence
exposure among children with disabilities.
In addition to the need for epidemiological studies of
violence perpetration against children and youth with dis-
abilities, other research is needed to guide violence pre-
vention and intervention efforts. Suggestions for future
research include:
• The perpetrator/victim relationship is an important
factor in identifying both risk factors for the victim-
ization and re-victimization of children and youth with
disabilities. Their victimization can occur in multiple
environments including the home, the school, in
residential placements, and in transportation modes
between them. The identification of the violence
perpetrator also has relevance to intervention modes
and goals for the psychological and mental health
effects of the victimization. Studies of the characteris-
tics of the victims and victimizers are rare and sorely
needed in the field of violence and disabilities.
• Disabilities are not commensurable and research is
needed in identifying the extent the violence victimiza-
tion of children and youth with specific disability types
impact the response of the criminal justice system to the
investigation of the alleged victimization, the interview-
ing methods utilized with the victim, and the disposition
of the investigation. If allegations of violence victimiza-
tion are consistently not pursued with certain disability
types, then collaborative efforts need to be forged and
evaluated through research of effective remedies to both
accommodate the disability and correct the justice
disparity for the specific disability group or groups.
• With the exception of corporal punishment, it is unknown
if children and youth with disabilities have a higher
victimization rate of condoned physical interventions
within residential settings that can escalate to abuse.
These include restraint and seclusion. The rates of
restraint and seclusion of children with disabilities need
to be compared with those of nondisabled peers in the
same settings and, importantly, their effectiveness in
behavior change for both groups. This research will need
to be undertaken by researchers who are not employed by
the residential placement in which it is conducted.
• Children and youth with disabilities who are both
physically and/or sexually aggressive toward other
children and youth are in particular need of study. We
need to know if aggression and anti-social behavior
Clin Child Fam Psychol Rev (2009) 12:196–216
increases their risk for violence victimization as well as
if these undesirable behaviors covary as a function of
type of their own violence victimization, perpetrator
characteristics, and type of disability.
• The UN Secretary General’s Study on Violence against
Children revealed emerging and burgeoning populations
of children with disabilities that are congenital and/or
acquired from land mines, intentional maiming, and
other violent acts perpetrated directly against them or
within their proximity. In addition to these children’s
immediate physical and caretaking needs, there are needs
for culturally sensitive and competent research to assist
in the determination of heuristic and efficacious inter-
ventions that meet their individual disability-specific
needs. It cannot be assumed that research conducted on
children and youth with disabilities in the U.S. will
generalize to children and youth with acquired disabil-
ities in other nations throughout the globe. New research
paradigms will need to be forged and implemented in
consort with researchers in these nations.
Acknowledgments The research summarized in this paper was
supported, in part, by grants from the U.S. Department of Health and
Human Services within the: Office on Child Abuse & Neglect (90 CA
1561 and 90 CA 1562); the Centers for Disease Control and Pre-
vention (R49/CCR722337-02); and the National Institutes of Health,
National Institute on Child Health and Human Development, and the
Office on Special Education Rehabilitation Services (5 R01
HD046991). The assistance of Deepa Srivastava and Calleen Zach is
gratefully acknowledged in the completion of this paper.
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